MANSFIELD ISD
BENEFIT GUIDE EFFECTIVE: 09/01/2019 - 8/31/2020 WWW.MYBENEFITSHUB.COM/MANSFIELDISD 1
Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) TRS-ActiveCare HSA Bank Health Savings Account (HSA) Cigna Hospital Indemnity MDLIVE Telehealth Cigna Dental Davis Vision AUL a OneAmerica Company Long Term Disability AUL a OneAmerica Company Life and AD&D 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider APL Cancer Voya Accident Voya Critical Illness NBS Flexible Spending Account (FSA) 2
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FLIP TO... PG. 4
HOW TO ENROLL
PG. 6
SUMMARY PAGES
PG. 12
YOUR BENEFITS
11 12-17 18-21 22-25 26-27 28-33 34-35 36-39 40-43 44-47 48-51 52-55 56-59 60-63
Benefit Contact Information BENEFIT ADMINISTRATORS
DENTAL
CANCER
Financial Benefit Services (800) 583-6908 www.mybenefitshub.com/mansfieldisd
Group # 3339927 Cigna (800) 244-6224 www.mycigna.com
Group # 18361 American Public Life (800) 256-8606 www.ampublic.com
MEDICAL
VISION
ACCIDENT
Aetna (800) 222-9205 www.trsactivecareaetna.com
Group # 7511 Davis Vision (877) 923-2847 www.davisvision.com
Group # 695149 Voya (800) 955-7736 www.voya.com
HEALTH SAVINGS ACCOUNT
DISABILITY
CRITICAL ILLNESS
HSA Bank (800) 357-6246 www.hsabank.com
Policy # G00614903 AUL a OneAmerica Company (800) 553-5318 Claims: (855) 517-6365 www.oneamerica.com
Group # 695149 Voya (800) 955-7736 www.voya.com
HOSPITAL INDEMNITY
FAMILY PROTECTION PLAN
FLEXIBLE SPENDING ACCOUNT
Cigna (800) 997-1654 www.cigna.com
5Star Life Insurance Company (866) 863-9753 http://5starlifeinsurance.com
National Benefit Services (800) 274-0503 www.nbsbenefits.com
TELEHEALTH
LIFE AND AD&D
MDLIVE (888) 365-1663 www.consultmdlive.com
Policy # G00614903 AUL a OneAmerica Company Customer Service: (800) 553-5318 Life/Life Waiver Claims: (800) 553-3522 Employee Assistance Program: (855) 387-9727 Travel Assistance Program: (866) 294-2469 www.oneamerica.com
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MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet. Text “FBS MISD” to 313131 and get access to everything you need to complete your benefits enrollment:
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•
Benefit Information
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Online Support
•
Interactive Tools
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And more.
Text “FBS MISD” to 313131 OR SCAN
How to Log In
1 BENEFIT INFO
INTERACTIVE TOOLS
2 3
mybenefitshub.com/mansfieldisd
CLICK LOGIN
ENTER USERNAME & PASSWORD All login credentials have been RESET to the default described below:
Username: The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.
ONLINE SUPPORT
If you have less than six (6) characters in your last name, use your full last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.
Default Password: Last Name (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number.
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Annual Benefit Enrollment
SUMMARY PAGES
Benefit Updates - What’s New: •
•
Medical: TRS ActiveCare medical plans will experience a • rate increase effective 09/01/2019, while the Scott and White HMO was a rate decrease. TRS-ActiveCare 1HD and TRS-ActiveCare Select rates will increase by 3%. TRS-ActiveCare 2 will increase by 8.9%. Scott & White HMO rates will decrease by 3.4%. ActiveCare 2 participants may elect to remain on the plan, no new enrollments will be allowed. Most plans experienced changes in Out-of-Pocket Maximums for In-Network and Out-of-Network as well as changes in prescription copay/coinsurance. Please visit www.trsactivecareaetna.com for complete details on • plan design changes for TRS medical plans. Cancer: CHANGE! Cancer by APL will now include a surgical, anesthesia, bone marrow transplant, stem cell transplant and prothesis benefit! The addition of the Surgical Rider does result in a slight premium increase. For more information on plan design changes, please visit www.mybenefitshub.com/mansfieldisd
• • •
Hospital Indemnity: New PLAN! Hospital Indemnity will be replacing the Medical Supplement Plan. While medical plans typically cover hospitalization, they don’t cover everything. Cigna’s plan will help you and your family with out -of- pocket costs associated with an inpatient hospital stay. If the hospital admits you, you will get a lump-sum payment! Additional benefits include a per-day and ICU benefit. Coverage is guaranteed issue, meaning you can won’t be turned away for prior health problems. This plan is HSA compatible and less expensive than the prior plan.
Reminder: Don’t forget to enroll yourself and your family for the MISD Clinic. This is a wonderful FREE benefit. Also be sure to review and update beneficiaries for your employer paid life insurance.
Login and complete your supplemental benefit enrollment from 07/01/2019 - 07/31/2019 Update your profile information: home address, phone numbers, email. IMPORTANT!! Due to the Affordable Care Act (ACA) reporting requirements, please add your dependent’s social security numbers in the online enrollment system. If you have questions, please contact your Benefits Administrator.
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SUMMARY PAGES
Section 125 Cafeteria Plan Guidelines A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer. Enrollment is automatic unless you decline this benefit. Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year. CHANGES IN STATUS (CIS): Marital Status
Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event. QUALIFYING EVENTS
A change in marital status includes marriage, death of a spouse, divorce or annulment (legal separation is not recognized in all states).
A change in number of dependents includes the following: birth, adoption and placement for adoption. Change in Number of Tax You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a Dependents result of a valid change in status event. Change in Status of Employment Affecting Coverage Eligibility
Change in employment status of the employee, or a spouse or dependent of the employee, that affects the individual's eligibility under an employer's plan includes commencement or termination of employment.
An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements Gain/Loss of Dependents' under an employer's plan may include change in age, student, marital, employment or tax dependent Eligibility Status status. If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child (including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order Judgment/Decree/Order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual's plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage. Eligibility for Government Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change. Programs
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SUMMARY PAGES
Annual Enrollment During your annual enrollment period, you have the opportunity
Where can I find forms?
to review, change or continue benefit elections each year.
For benefit summaries and claim forms, go to your school
Changes are not permitted during the plan year (outside of
district’s benefit website: www.mybenefitshub.com/
annual enrollment) unless a Section 125 qualifying event occurs.
mansfieldisd. Click on the benefit plan you need information on (i.e., Dental) and you can find the forms you need under
•
Changes, additions or drops may be made only during the
the Benefits and Forms section.
annual enrollment period without a qualifying event. How can I find a Network Provider?
• Employees must review their personal information and verify that dependents they wish to provide coverage for are
district’s benefit website: www.mybenefitshub.com/
included in the dependent profile. Additionally, you must
mansfieldisd. Click on the benefit plan you need information
notify your employer of any discrepancy in personal and/or benefit information.
•
For benefit summaries and claim forms, go to your school
Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.
on (i.e., Dental) and you can find provider search links under the Quick Links section. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and
New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within the first 31 days of benefit eligibility employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.
verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card. If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.
Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 866-914-5202 for assistance.
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SUMMARY PAGES
Employee Eligibility Requirements
Dependent Eligibility Requirements
Supplemental Benefits: Eligible employees must work 18 or more
Dependent Eligibility: You can cover eligible dependent
regularly scheduled hours each work week.
children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the
Eligible employees must be actively at work on the plan effective
maximum age listed below. Dependents cannot be double
date for new benefits to be effective, meaning you are physically
covered by married spouses within Mansfield ISD or as both
capable of performing the functions of your job on the first day of
employees and dependents.
work concurrent with the plan effective date. For example, if your 2019 benefits become effective on September 1, 2019, you must be actively-at-work on September 1, 2019 to be eligible for your new benefits.
PLAN
CARRIER
MAXIMUM AGE
Medical
Aetna
Through 25
Hospital Indemnity
Cigna
Through 25
Telehealth
MDLIVE
Through 25
Dental
Cigna
Through 25
Vision
Davis Vision
Through 25
Accident
VOYA
Through 25
Cancer
American Public Life
Through 25
Life and AD&D
AUL a OneAmerica company
Through 25
Critical Illness
VOYA
Through 25
Individual Life
5Star
Through 23
Health Savings Account (HSA)
HSA Bank
IRS Tax Dependent
Flexible Spending Account (FSA)
National Benefit Services
Through 25 or IRS Tax Dependent
National Benefit Services
12 or younger or qualified individual unable to care for themselves & claimed as a dependent on your taxes
Dependent Flex
If your dependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your HR/Benefit Administrator to request a continuation of coverage. 9
Helpful Definitions
SUMMARY PAGES
Actively at Work
In-Network
You are performing your regular occupation for the employer
Doctors, hospitals, optometrists, dentists and other providers
on a full-time basis, either at one of the employer’s usual
who have contracted with the plan as a network provider.
places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2019 please notify your benefits administrator.
Annual Enrollment The period during which existing employees are given the opportunity to enroll in or change their current elections.
Annual Deductible The amount you pay each plan year before the plan begins to pay covered expenses.
Out of Pocket Maximum The most an eligible or insured person can pay in co-insurance for covered expenses.
Plan Year September 1st through August 31st
Pre-Existing Conditions Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescriptions drugs or is under a health care provider’s orders to take drugs, or received medical care or services
Calendar Year January 1st through December 31st
Co-insurance After any applicable deductible, your share of the cost of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service.
Guaranteed Coverage The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period. Actively-at-work and/or pre-existing condition exclusion provisions do apply, as applicable by carrier.
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(including diagnostic and/or consultation services).
SUMMARY PAGES
HSA vs. FSA Health Savings Account (HSA) (IRC Sec. 223)
Flexible Spending Account (FSA) (IRC Sec. 125)
Approved by Congress in 2003, HSAs are actual bank accounts in employee’s names that allow employees to save and pay for unreimbursed qualified medical expenses tax-free.
Allows employees to pay out-of-pocket expenses for copays, deductibles and certain services not covered by medical plan, tax-free. This also allows employees to pay for qualifying dependent care taxfree.
Employer Eligibility
A qualified high deductible health plan.
All employers
Contribution Source Account Owner Underlying Insurance Requirement
Employee and/or employer Individual
Employee and/or employer Employer
High deductible health plan
None
Description
Minimum Deductible Maximum Contribution
Permissible Use Of Funds
$1,350 single (2019) $2,700 family (2019) $3,500 single (2019) $7,000 family (2019) Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.
N/A $2,700 Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).
Cash-Outs of Unused Amounts (if no medical expenses)
Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65).
Not permitted
Year-to-year rollover of account balance?
Yes, will roll over to use for subsequent year’s health coverage.
No. Access to some funds can may be extended if your employer’s plan contains a 2 1/2 –month grace period or $500 rollover provision.
Does the account earn interest?
Yes
No
Portable?
Yes, portable year-to-year and between jobs.
No
FLIP TO FOR HSA INFORMATION
PG. 18
FLIP TO FOR FSA INFORMATION
PG. 60 11
AETNA
Medical
About this Benefit
YOUR BENEFITS PACKAGE
DID YOU KNOW?
Major medical insurance is a type of health care coverage that provides benefits for a broad range of medical expenses that may be incurred either on an inpatient or outpatient basis. More than 70% of adults across the United States are already being diagnosed with a chronic disease.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 12 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Mansfield ISD Benefits Website: www.mybenefitshub.com/mansfieldisd
2019 – 20 TRS-ActiveCare Plan Highlights Effective Sept. 1, 2019 through Aug. 31, 2020 | In-Network Level of Benefits1 TRS-ActiveCare 1-HD
TRS-ActiveCare Select or TRS-ActiveCare Select Whole Health
TRS-ActiveCare 2
(Baptist Health System and HealthTexas Medical Group; Baylor Scott and White Quality Alliance; Kelsey Select; Memorial Hermann Accountable Care Network; Seton Health Alliance)
NOTE: If you’re currently enrolled in TRSActiveCare 2, you can remain in this plan. However, as of Sept. 1, 2018, TRS-ActiveCare 2 is closed to new enrollees.
$500 copay per visit plus 20% after deductible
$500 copay per visit plus 20% after deductible
Deductible (per plan year) In-Network Out-of-Network Out-of-Pocket Maximum (per plan year; medical and prescription drug deductibles, copays, and coinsurance count toward the out-of-pocket maximum) In-Network Out-of-Network Coinsurance In-Network Participant pays (after deductible) Out-of-Network Participant pays (after deductible) Office Visit Copay Participant pays Diagnostic Lab Participant pays Preventive Care See below for examples Teladoc® Physician Services
High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays Inpatient Hospital Facility Charges Only (preauthorization required) In-Network
Out-of-Network
Urgent Care Freestanding Emergency Room Participant pays
$500 copay per visit plus 20% after deductible
Emergency Room (true emergency use) Participant pays Outpatient Surgery Participant pays Bariatric Surgery (only covered if performed at an 10Q facility) Physician charges; Participant pays Annual Vision Examination (one per plan year; performed by an ophthalmologist or optometrist)Participant pays Annual Hearing Examination Participant pays Preventive Care Some examples of preventive care frequency and services: • • • •
Routine physicals – annually age 12 and over Mammograms – 1 every year age 35 and over Smoking cessation counseling – 8 visits per 12 months Well-child care – unlimited up to age 12
• • •
Colonoscopy – one every 10 years age 50 and over Healthy diet/obesity counseling – unlimited to age 22; age 22 and over – 26 visits per 12 months Well woman exam & pap smear – annually age 18 and over
• •
Prostate cancer screening – one per year age 50 and over Breastfeeding support – six lactation counseling visits per 12 months
Note: Covered services under this benefit must be billed by the provider as “preventive care.” Non-network preventive care is not paid at 100%. If you receive preventive services from a non-network provider, you will be responsible for any applicable deductible and coinsurance under the TRS-ActiveCare 1-HD and TRS-ActiveCare 2. There is no coverage for non-network services under the TRS-ActiveCare 13 Select plan or TRS-ActiveCare Select Whole Health. For more information, please view the Benefits Booklet at www.trsactivecareaetna.com. TRS-ActiveCare is administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug benefits are administered by Caremark
2019 – 20 TRS-ActiveCare Plan Highlights TRS-ActiveCare 1-HD
TRS-ActiveCare Select or ActiveCare Select Whole Health
TRS- ActiveCare 2
(Baptist Health System and HealthTexas Medical Group; Baylor Scott and White Quality Alliance; Kelsey Select; Memorial Hermann Accountable Care Network; Seton Health Alliance)
NOTE: If you’re currently enrolled in TRS-ActiveCare 2, you can remain in this plan. However, as of Sept. 1, 2018, TRS-ActiveCare 2 is closed to new enrollees.
Drug Deductible Short-Term Supply at a Retail Location 20% coinsurance after deductible, except for certain generic preventive $15 copay drugs that are covered at 100%.2 25% coinsurance after deductible3 25% coinsurance (min. $404; max. $80)3 3 50% coinsurance after deductible 50% coinsurance3 Extended-Day Supply at Mail Order or Retail-Plus Pharmacy Location (60- to 90-day supply)5 20% coinsurance after deductible $45 copay 25% coinsurance after deductible3 25% coinsurance (min. $1054; max. $210)3 50% coinsurance after deductible3 50% coinsurance3 Specialty Medications (up to a 31-day supply)
$20 copay 25% coinsurance (min. $404; max. $80)3 50% coinsurance (min. $1004; max. $200)3 $45 copay 25% coinsurance (min. $1054; max. $210)3 50% coinsurance (min. $2154; max. $430)3 20% coinsurance (min. $2004 , max $900)
Specialty Medications
20% coinsurance after deductible 20% coinsurance Short-Term Supply of a Maintenance Medication at Retail Location up to a 31-day supply
The second time a participant fills a short-term supply of a maintenance medication at a retail pharmacy, they will be charged the coinsurance and copays in the rows below. Participants can save more over the plan year by filling a larger day supply of a maintenance medication through mail order or at a Retail-Plus location.
Tier 1 – Generic Tier 2 – Preferred Brand Tier 3 – Non-Preferred Brand
20% coinsurance after deductible 25% coinsurance after deductible3 50% coinsurance after deductible3
$30 copay 25% coinsurance (min. $604; max. $120)3 50% coinsurance3
$35 copay 25% coinsurance (min. $604; max. $120)3 50% coinsurance (min. $1054; max. $210)3
What is a maintenance medication? Maintenance medications are prescriptions commonly used to treat conditions that are considered chronic or long-term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma and diabetes.
When does the convenience fee apply? For example, if you are covered under TRS-ActiveCare Select, the first time you fill a 31-day supply of a generic maintenance drug at a retail pharmacy you will pay $15, then you will pay $30 each month that you fill a 31-day supply of that generic maintenance drug at a retail pharmacy. A 90-day supply of that same generic maintenance medication would cost $45, and you would save $180 over the year by filling a 90-day supply. A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. 1 Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the TRS-ActiveCare Select or TRS-ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. 2 For TRS-ActiveCare 1-HD, certain generic preventive drugs are covered at 100%. Participants do not have to meet the deductible ($2,750 – individual, $5,500 – family) and they pay nothing out of pocket for these drugs. Find the list of drugs at info.caremark.com/trsactivecare. 3 If a participant obtains a brand-name drug when a generic equivalent is available, they are responsible for the generic copay plus the cost difference between the brand-name drug and the generic drug. 4 If the cost of the drug is less than the minimum, you will pay the cost of the drug. 5 Participants can fill 32-day to 90-day supply through mail order.
Monthly Premiums
Full monthly premium*
Premium with min. state/ district contribution**
$378
+Spouse +Children +Family
Individual
Your Monthly Premium***
Full monthly premium*
Premium with min. state/ district contribution**
$153
$556
$1,066
$841
$722
$497
$1,415
$1,190
Your Monthly Premium***
Full monthly premium*
Premium with min. state/ district contribution**
$331
$852
$627
$1,367
$1,142
$2,020
$1,795
$902
$677
$1,267
$1,042
$1,718
$1,493
$2,389
$2,164
Your Monthly Premium***
* If you are not eligible for the state/district subsidy, you will pay the full monthly premium. Please contact your Benefits Administrator for your monthly premium. ** The premium after state, $75 and district, $150 contribution is the maximum you may pay per month. Ask your Benefits Administrator for your monthly cost. (This is the amount you will owe each month after all available subsidies are applied to your premium.) *** Completed by your benefits administrator. The state/district contribution may be greater than $225. 14
2019-2020 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Fully Covered Healthcare Services
Copay
Preventive Services
No Charge
Standard Lab and X-Ray
No Charge
Disease Management and Complex Case Management
No Charge
Well Child Care Annual Exams
No Charge
Immunizations (age appropriate)
No Charge
Plan Provisions
Copay
Annual Deductible
$950 Individual/ $2,850 Family
Annual out-of-pocket maximum (including medical and prescription copays and coinsurance)
$7,450 Individual/ $14,900 Family (includes combined Medical and RX copays, deductibles and coinsurance)
Lifetime Paid Benefit Maximum
None
Outpatient Services
Copay $20 copay
Primary Care1
(First Primary Care Visit for Illness - $0 Copay2) / $0 Copay for primary visit for dependents age 19 and under)
Specialty Care
$70 copay
Other Outpatient Services
20% after deductible3
Diagnostic/Radiology Procedures
20% after deductible
Eye Exam (one annually)
No Charge
Allergy Serum & Injections
20% after deductible
Outpatient Surgery
$150 copay and 20% of charges after deductible
Maternity Care
Copay
Prenatal Care Inpatient Delivery
Inpatient Services Overnight hospital stay: includes all medical services including semi -private room or intensive care
Diagnostic & Therapeutic Services Physical and Speech Therapy Manipulative Therapy5
Equipment and Supplies Preferred Diabetic Supplies and Equipment Non-Preferred Diabetic Supplies and Equipment Durable Medical Equipment/ Prosthetics
No Charge 4
$150 per day and 20% of charges after deductible
Copay $150 per day4 and 20% of charges after deductible
Copay $70 copay 20% without office visit $40 plus 20% with office visit
Copay $5/$12.50 copay; no deductible 30% after Rx deductible 20% after deductible 15
2019-2020 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Home Health Services
Copay
Home Healthcare Visit
$70 copay
Worldwide Emergency Care
Copay
Nurse Advice Line
1-877-505-7947
Online Services
No Charge — go to trs.swhp.org
After-Hours Primary Care Clinics
$20 copay
Ambulance and Helicopter
$40 copay and 20% of charges after deductible
Emergency Room6
$500 copay after deductible
Urgent Care Facility
$50 copay
Prescription Drugs
Copay
Annual Benefit Maximum
Unlimited
Rx Deductible
$150
Does not apply to preferred generic drugs
Ask an SWHP Pharmacy representative how to save money on your prescriptions.
Maintenance Quantity (Up to a 30-day supply)
(Up to a 90-day supply) Available at BSW Pharmacies, in-network retail pharmacies and mail order
$5 copay
$12.50 copay
Preferred Brand
30% after Rx deductible
30% after Rx deductible
Non-Preferred
50% after Rx deductible
50% after Rx deductible
Preferred Generic
Online Refills Mail Order
Specialty Medications
Retail Quantity
trs.swhp.org BSWH: 1-817-388-3090 OptumRx: 1-855-205-9182
Copay Tier 1: 15% after Rx deductible
(Up to a 30-day supply)
Tier 2: 15% after Rx deductible Tier 3: 25% after Rx deductible
1
Including all services billed with office visit Does not apply to wellness or preventive visits 3 Includes other services, treatments, or procedures received at time of office visit 4 $750 maximum copay per admission and 20% after deductible 5 35 maximum visit per year 6 Copay waived if admitted within 24 hours 2
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The SWHP MOMS Program provides you with professional nurses who are notified of the delivery of your baby. These licensed professionals will contact you after you return home and help you with everything from the general well-being of both you and your baby, to breast/bottle feeding, to information on how to add your baby to your health plan.
Medical Rates TRS ActiveCare 1-HD Monthly Premium Cost
TRS Cost
Your Cost*
$378
$128
$1,066
$816
$722
$472
$1,415
$1,165
TRS Cost
Your Cost*
$556
$306
$1,367
$1,117
$902
$652
$1,718
$1,468
TRS Cost
Your Cost*
$852
$602
Employee and Spouse
$2,020
$1,770
Employee and Child(ren)
$1,267
$1,017
Employee and Family
$2,389
$2,139
Monthly Premium Cost
TRS Cost
Your Cost*
Employee Only
$558.54
$308.54
$1,306.58
$1,056.58
$876.76
$626.76
$1,457.28
$1,207.28
Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
TRS ActiveCare Select Monthly Premium Cost Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
TRS ActiveCare 2 Monthly Premium Cost
Employee Only
Scott & White HMO
Employee and Spouse Employee and Child(ren) Employee and Family
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HSA BANK
HSA (Health Savings Account)
About this Benefit A Health Savings Account is a tax-advantaged medical savings account available to employees who are enrolled in a high-deductible health plan. The funds contributed to the account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), funds roll over and accumulate year to year if not spent.
YOUR BENEFITS PACKAGE
The interest earned in an HSA is tax free.
Money withdrawn for medical spending never falls under taxable income.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 18 details on covered expenses, limitations and exclusions included in the summary plan description located on the Mansfield ISD Benefits Website:are www.mybenefitshub.com/mansfieldisd Mansfield ISD Benefits Website: www.mybenefitshub.com/mansfieldisd
HSA (Health Savings Account) HSA Bank has teamed up with your employer to create an affordable health coverage option that helps you save on healthcare expenses. This plan is only available for those who are participating in the Active Care 1-HD medical plan. You may not enroll in the Traditional Gap Plan if you participate in the HSA. You may not participate in the FSA plan if you participate in HSA. Medicare, Medicaid, and Tricare participants are not eligible to participate in an HSA. You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.
What is an HSA? •
• •
A tax-advantaged savings account that you use to pay for eligible medical expenses as well as deductible, co-insurance, prescriptions, vision and dental care. Allows you to save while reducing your taxable income. Unused funds that will roll over year to year. There’s no “use it or lose it” penalty. A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.
Authorized Signers who are 55 or older must have their own HSA in order to make the catch-up contribution Monthly Fee: Your account will be charged a monthly fee of $1.75, waived with an average daily balance at or above $3,000.
Examples of Qualified Medical Expenses • • • • • •
Surgery Braces Contact lenses Dentures Eyeglasses Vaccines
For a list of sample expenses, please refer to the Mansfield ISD website at www.thebenefitshub.com/mansfieldisd
HSA Bank Contact Information 605 N. 8th Street, Ste 320 Sheboygan, WI 53081 Phone: 800-357-6246 www.hsabank.com
Using Funds Debit Card • You may use the card to pay merchants or service providers that accept VISA credit cards, so there is no need to pay cash up front and wait for reimbursements. • You can make a withdrawal at any time. Reimbursements for qualified medical expenses are tax free. If you are disabled or reach age 65, you can receive non-medical distributions without penalty, but you must report the distributions as taxable income. You may also use your funds for a spouse or tax dependent not covered by your HDHP.
2019 Annual HSA Contribution Limits Individual: $3,500 Family: $7,000 Catch-Up Contributions: Accountholders who meet the qualifications noted below are eligible to make an HSA catch-up contribution of an additional $1,000. • Health Savings accountholder • Age 55 or older (regardless of when in the year an accountholder turns 55) • Not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated)
19
How the HSA Plan Works A Health Savings Account (HSA) is an individually-owned, tax-advantaged account that you can use to pay for current or future IRS-qualified medical expenses. With an HSA, you’ll have the potential to build more savings for healthcare expenses or additional retirement savings through self-directed investment options1.
How an HSA works: •
•
• •
You can contribute to your HSA via payroll deduction, online banking transfer, or by sending a personal check to HSA Bank. Your employer or third parties, such as a spouse or parent, may contribute to your account as well. You can pay for qualified medical expenses with your HSA Bank Debit Card directly to your medical provider or pay out-of-pocket. You can either choose to reimburse yourself or keep the funds in your HSA to grow your savings. Unused funds will roll over year to year. After age 65, funds can be withdrawn for any purpose without penalty (subject to ordinary income taxes). Check balances and account information via HSA Bank’s Internet Banking 24/7.
Are you eligible for an HSA? If you have a qualified High Deductible Health Plan (HDHP) either through your employer, through your spouse, or one you’ve purchased on your own - chances are you can open an HSA. Additionally: • You cannot be covered by any other non-HSA-compatible health plan, including Medicare Parts A and B. • You cannot be covered by TriCare. • You cannot have accessed your VA medical benefits in the past 90 days (to contribute to an HSA). • You cannot be claimed as a dependent on another person’s tax return (unless it’s your spouse). • You must be covered by the qualified HDHP on the first day of the month. When you open an account, HSA Bank will request certain information to verify your identity and to process your application.
What are the annual IRS contribution limits? Contributions made by all parties to an HSA cannot exceed the annual HSA limit set by the Internal Revenue Service (IRS). Anyone can contribute to your HSA, but only the accountholder and employer can receive tax deductions on those contributions. Combined annual contributions for the accountholder, employer, and third parties (i.e., parent, spouse, or anyone else) must not exceed these limits2. 20
2019 Annual HSA Contribution Limits Individual = $3,500 Family = $7,000
Catch-up Contributions Accountholders who meet these qualifications are eligible to make an HSA catch-up contribution of $1,000: Health Savings accountholder; age 55 or older (regardless of when in the year an accountholder turns 55); not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated). Authorized signers who are 55 or older must have their own HSA in order to make the catch-up contribution. According to IRS guidelines, each year you have until the tax filing deadline to contribute to your HSA (typically April 15 of the following year). Online contributions must be submitted by 2:00 p.m., Central Time, the business day before the tax filing deadline. Wire contributions must be received by noon, Central Time, on the tax filing deadline, and contribution forms with checks must be received by the tax filing deadline.
How can you benefit from tax savings? An HSA provides triple tax savings3. Here’s how: • Contributions to your HSA can be made with pre-tax dollars and any after-tax contributions that you make to your HSA are tax deductible. • HSA funds earn interest and investment earnings are tax free. • When used for IRS-qualified medical expenses, distributions are free from tax.
IRS-Qualified Medical Expenses You can use your HSA to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse, or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free. HSA funds can be used to reimburse yourself for past medical expenses if the expense was incurred after your HSA was established. While you do not need to submit any receipts to HSA Bank, you must save your bills and receipts for tax purposes.
How the HSA Plan Works Examples of IRS-Qualified Medical Expenses4: Acupuncture Alcoholism treatment Ambulance services Annual physical examination Artificial limb or prosthesis Birth control pills (by prescription) Chiropractor Childbirth/delivery Convalescent home (for medical treatment only) Crutches Doctor’s fees Dental treatments (including x-rays, braces, dentures, fillings, oral surgery) Dermatologist Diagnostic services Disabled dependent care Drug addiction therapy Fertility enhancement (including in-vitro fertilization) Guide dog (or other service animal)
Gynecologist Hearing aids and batteries Hospital bills Insurance premiums5 Laboratory fees Lactation expenses Lodging (away from home for outpatient care) Nursing home Nursing services Obstetrician Osteopath Oxygen Pregnancy test kit Podiatrist Prescription drugs and medicines (over-the-counter drugs are not IRSqualified medical expenses unless prescribed by a doctor) Prenatal care & postnatal treatments Psychiatrist Psychologist Smoking cessation programs
Special education tutoring Surgery Telephone or TV equipment to assist the hearing or vision impaired Therapy or counseling Medical transportation expenses Transplants Vaccines Vasectomy Vision care (including eyeglasses, contact lenses, lasik surgery) Weight loss programs (for a specific disease diagnosed by a physician – such as obesity, hypertension, or heart disease) Wheelchairs X-rays
For assistance, please contact the Client Assistance Center 800-357-6246 Monday – Friday, 7 a.m. – 9 p.m., and Saturday, 9 a.m. - 1 p.m., CT www.hsabank.com | 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081
1 Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. 2 HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed. 3 Federal Tax savings are available no matter where you live and HSAs are taxable in AL, CA, and NJ. HSA Bank does not provide tax advice. Consult your tax professional for tax‐related questions. 4 This list is not comprehensive. It is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intended to be used to avoid Federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses”. Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional. 5 Insurance premiums only qualify as an IRS-qualified medical expense: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage). 21
CIGNA YOUR BENEFITS PACKAGE
Hospital Indemnity
About this Benefit Hospital Confinement Indemnity Insurance pays a daily benefit if you have a covered stay in a hospital*, critical care unit and rehabilitation facility. The benefit amount is determined based on the type of facility and the number of days you stay. Hospital Confinement Indemnity Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.
The median hospital costs per stay have steadily grown to over $10,500 per day.
$9,600
$10,400
$10,700
2008
2012
2018
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 22 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Mansfield ISD Benefits Website: www.mybenefitshub.com/mansfieldisd
Hospital Indemnity SUMMARY OF BENEFITS Hospital Care coverage provides a benefit according to the schedule below when a Covered Person incurs a Hospital stay resulting from a Covered Injury or Covered Illness. See State Variations (marked by *) below.
Who Can Elect Coverage: You: All active, full-time Employees of the Employer who are regularly working in the United States a minimum of 18 hours per week and regularly residing in the United States and who are United States citizens or permanent resident aliens and their Spouse/Domestic Partner and Dependent Children who are United States citizens or permanent resident aliens and who are residing in the United States. You will be eligible for coverage the first of the month following date of hire. Your Spouse/Domestic Partner: Up to age 100, as long as you apply for and are approved for coverage yourself. Your Child(ren): Birth to 26; 26+ if disabled, as long as you apply for and are approved for coverage yourself. Available Coverage: The benefit amounts shown in this summary will be paid regardless of the actual expenses incurred. Benefits are only payable when all policy terms and conditions are met. Please read all the information in this summary to understand the terms, conditions, state variations, exclusions and limitations applicable to these benefits. See your Certificate of Insurance for more information.
Portability Feature:* You, your spouse, and child(ren) can continue 100% of your coverage at the time your coverage ends. You must be covered under the policy and be under the age of 100 in order to continue your coverage. Rates may change and all coverage ends at age 100. Applies to United States Citizens and Permanent Resident Aliens residing in the United States.
Employee’s Monthly Cost of Coverage: Tier Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
Plan 1 $17.29 $31.75 $28.72 $43.18
Plan 2 $34.15 $62.81 $56.87 $85.53
Costs are subject to change. Actual per pay period premiums may differ slightly due to rounding.
NOTE: The following are some of the important policy provisions, terms and conditions that apply to benefits described in the policy. This is not a complete list. See your Certificate of Insurance for more information. Benefit Amounts Payable: Benefits for all Covered Persons are payable at 100% of the Benefit Amounts shown, unless otherwise stated. Late applicants, if allowed under this plan, may be required to provide medical evidence of insurability.
Benefit-Specific Conditions, Exclusions & Limitations (Hospital Care):
Hospital Admission: Must be admitted as an Inpatient due to a Covered Injury or Covered Illness. Excludes: treatment in an Benefit Waiting Period:* 0 days following the effective date, unless otherwise stated. No benefits will be paid for a loss which emergency room, provided on an outpatient basis, or for readmission for the same Covered Injury or Covered Illness. occurs during the Benefit Waiting Period. Hospitalization Benefits
Plan 1
Plan 2
Hospital Admission No Elimination Period. Limited to 1 day, 1 benefit(s) every 365 days.
$1,500 per day
$3,000 per day
Hospital Chronic Condition Admission No Elimination Period. Limited to 1 day, 1 benefit(s) every 365 days.
$50 per day
$50 per day
Hospital Stay No Elimination Period. Limited to 30 days, 1 benefit(s) every 365 days.
$100 per day
$200 per day
Hospital Intensive Care Unit (ICU) Stay No Elimination Period. Limited to 30 days, 1 benefit(s) every 365 days.
$100 per day
$200 per day
Hospital Observation Stay 24 hour Elimination Period. Limited to 72 hours.
$100 per 24-hour period
$100 per 24-hour period
NOTE: This insurance is NOT a substitute for comprehensive or major medical insurance coverage.
Hospital Chronic Condition Admission: Must be admitted as an Inpatient due to a covered chronic condition and treatment for the covered chronic condition must be provided by a specialist in that field of medicine. Excludes: treatment in an emergency room, provided on an outpatient basis, or for re-admission for the same Covered Injury or Covered Illness (including chronic conditions). Hospital Stay: Must be admitted as an Inpatient and confined to the Hospital, due to a Covered Injury or Covered Illness, at the direction and under the care of a physician. If also eligible for the ICU Stay Benefit, only 1 benefit will be paid for the same Covered Injury or Covered Illness, whichever is greater. Hospital stays within 30 days for the same or a related Covered Injury or Covered Illness is considered one Hospital Stay. Intensive Care Unit (ICU) Stay: Must be admitted as an Inpatient and confined in an ICU of a Hospital, due to a Covered Injury or Covered Illness, at the direction and under the care of a physician. If also eligible for the Hospital Stay Benefit, only 1 benefit will be paid for the same Covered Injury or Covered Illness, whichever is greater. ICU stays within 30 days for the same or a related Covered Injury or Covered Illness is considered one ICU stay. 23
Hospital Indemnity Hospital Observation Stay: Must be receiving treatment for a living in the Covered Person’s household; Covered Injury or Covered Illness in a Hospital, including an a parent, sibling, spouse or child of the Covered Person. observation room, or ambulatory surgical center, for more than 24 hour on a non-inpatient basis and a charge must be incurred. Important Definitions: This benefit is not payable if a benefit is payable under the Covered Illness: A physical or mental disease or disorder including Hospital Stay Benefit or Hospital Intensive Care Unit Stay Benefit. pregnancy and complications of pregnancy that results in a covered loss. A Covered Illness includes medically-necessary Common Exclusions and Limitations: quarantine in a Hospital in conjunction with medically-necessary Exclusions:* In addition to any benefit-specific exclusion, benefits preventive treatment due to an identifiable exposure to a lifewill not be paid for any Covered Injury or Covered Illness which is threatening contagious and infectious disease. caused by or results from any of the following (unless otherwise provided for in the policy): Covered Injury: Any bodily harm that results in a covered loss. • (1) intentionally self-inflicted injury, suicide or any attempted Covered Person: An eligible person, as defined in the Schedule of threat while sane or insane; • (2) commission or attempt to commit a felony or an assault; Benefits, who is enrolled and for whom Evidence of Insurability, where required, has been accepted by Us, required premium has • (3) declared or undeclared war or act of war; been paid when due, and coverage under this Policy remains in • (4) a Covered Injury or Covered Illness that occurs while on force. active duty service in the military, naval or air force of any
•
•
•
•
• •
country or international organization. Upon our receipt of proof of service, we will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days; (5) voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage (excludes WA residents); (6) operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the Covered Person has been provided a written warning against operating a vehicle while taking it. “Under the influence of alcohol”, for purposes of this exclusion, means intoxicated, as defined by the law of the state in which the Covered Injury or Covered Illness occurred. (excludes WA residents) Those not necessary, as determined by Us in accordance with generally accepted standards of medical practice, for the diagnosis, care or treatment of the physical or mental condition involved. This applies even if they are prescribed, recommended, or approved by the attending physician. Elective or cosmetic surgery. This does not include reconstructive, cosmetic surgery: a) incidental to or following surgery for trauma, infection or other disease of the involved part; or b) due to congenital disease or anomaly of a Covered Dependent child which has resulted in a functional defect. Dental surgery, unless the surgery is the result of an accidental injury; In addition, benefits will not be paid for services or treatment rendered by a Physician, Nurse or any other person who is: Employed or retained by the Subscriber; providing homeopathic, aroma-therapeutic or herbal therapeutic services; 24
Elimination Period: The continuous period of time that must be satisfied before a benefit shown in the Schedule of Benefits is payable. An Elimination Period may be satisfied during the Policy’s Benefit Waiting Period. Hospital:* An institution that is licensed as a hospital pursuant to applicable law; primarily and continuously engaged in providing medical care and treatment to sick and injured persons; managed under the supervision of a staff of physicians; provides 24-hour nursing services by or under the supervision of a graduate registered Nurse (R.N.); and has medical, diagnostic and treatment facilities with major surgical facilities on its premises, or available to it on a prearranged basis. The term Hospital does not include a clinic, facility, or unit of a Hospital for: (1) rehabilitation, convalescent, custodial, educational, hospice, or skilled nursing care; (2) the aged, drug addicts or alcoholics; or (3) a facility primarily or solely providing psychiatric services to mentally ill patients.
Policy Provisions: When your coverage begins: Coverage begins on the later of the program’s effective date, the date you become eligible, the first of the month following the date your completed enrollment form is received or if evidence of insurability is required, the first of the month after we have approved you (or your dependent) for coverage in writing unless otherwise agreed upon by Cigna. Your coverage will not begin unless you are actively at work on the effective date. Coverage for Covered Persons will not begin on the effective date if the covered person is confined to a hospital, facility or at home; disabled or receiving disability benefits or unable to perform activities of daily living. When your coverage ends: Coverage for any Covered Person ends on the earliest of the date they are no longer eligible, the date the group policy is no longer in force, or the date for the last period for which required premiums are paid. For your Spouse and Dependent Child(ren), if applicable, coverage also ends when
Hospital Indemnity your coverage ends, when their premiums are not paid or when they are no longer eligible. (Under certain circumstances, your coverage may be continued if you stop working. Be sure to read the Continuation of Insurance provisions in your Certificate.) 30 Day Right To Examine Certificate: If a Covered Person is not satisfied with the Certificate for any reason, it may be returned to us within 30 days after receipt. We will return any premium that has been paid and the Certificate will be void as if it had never been issued. *State Variations Spouse definition includes civil union partners in New Hampshire and Vermont. Portability in VT is referred to as Continuation due to loss of eligibility. VT residents are not subject to the age limit to continue coverage. Exclusions may vary for residents of MN, SC, SD, and WA. Important Definitions (Hospital) includes stays in substance abuse and mental nervous facilities in VT. Series 1.0/1.1 THIS POLICY PAYS LIMITED BENEFITS ONLY. IT DOES NOT CONSTITUTE COMPREHENSIVE HEALTH INSURANCE COVERAGE AND IS NOT INTENDED TO COVER ALL MEDICAL EXPENSES. THIS COVERAGE DOES NOT SATISFY “MINIMUM ESSENTIAL COVERAGE” OR INDIVIDUAL MANDATE REQUIREMENTS OF THE AFFORDABLE CARE ACT (ACA). THIS COVERAGE IS NOT A MEDICAID OR MEDICARE SUPPLEMENT POLICY. This is not intended as a complete description of the insurance coverage offered. This is not a contract. Full terms and conditions of coverage are defined by and governed by Group Policy No.HC 960464. Please see your Plan Sponsor to obtain a copy of the Policy. If there are any differences between this summary and the Group Policy, the information in the Group Policy takes precedence. Product availability, costs, benefits, riders and/or features may vary by state. Please keep this material as a reference. Insurance coverage is issued on group policy form number: Policy Form GHIP-00-1000.00. Coverage is underwritten by Life Insurance Company of North America, 1601 Chestnut St. Philadelphia, PA 19192. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Life Insurance Company of North America. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 887511 1/18 © 2019 Cigna. Some content provided under license.
25
MDLIVE
Telehealth
About this Benefit Telehealth provides 24/7/365 access to boardcertified doctors via telephone consultations that can diagnose, recommend treatment and prescribe medication. Whether you are at home, traveling or at work, Telehealth makes care more convenient and accessible for non-emergency care when your primary care physician is not available.
YOUR BENEFITS PACKAGE
75%
of all doctor, urgent care, and ER visits could be handled safely and effectively via telehealth.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 26 details on covered expenses, limitations and exclusions included in the summary plan description located on the Mansfield ISD Benefits Website:are www.mybenefitshub.com/mansfieldisd Mansfield ISD Benefits Website: www.mybenefitshub.com/mansfieldisd
Telehealth When should I use MDLIVE? • If you’re considering the ER or urgent care for a non-emergency medical issue • Your primary care physician is not available • At home, traveling, or at work • 24/7/365, even holidays!
What can be treated? • • • • • • • • •
Allergies Asthma Bronchitis Cold and Flu Ear Infections Joint Aches and Pain Respiratory Infection Sinus Problems And More!
Pediatric Care related to: • • • • • • •
Cold & Flu Constipation Ear Infection Fever Nausea & Vomiting Pink Eye And More!
Are children eligible? Yes. MDLIVE has local pediatricians on-call 24/7/365. Please note, a parent or guardian must be present during any interactions involving minors. We ask parents to establish a child record under their account. Parents must be present on each call for children 18 or younger.
How much does it cost? $10 per month; See your pay rate below. Covers you, your spouse, and children up to age 26, with unlimited phone consultations. 12 Pay Rate: $10.00 18 Pay Rate: $6.67 26 Pay Rate: $4.62
Download the App Doctor visits are easier and more convenient with the MDLIVE App. Be prepared. Download today. www.mdlive.com/getapp • • • • •
Access to a doctor anywhere: at home, at work, or on the go Choose doctors from one of the nation's largest telehealth networks Available 24/7 by video or phone Private, secure and confidential visits Connect instantly with MDLIVE Assist
Who are our doctors? MDLIVE has the nation’s largest network of telehealth doctors. On average, our doctors have 15 years of experience practicing medicine and are licensed in the state where patients are located. Their specialties include primary care, pediatrics, emergency medicine and family medicine. Our doctors are committed to providing convenient, quality care and are always ready to take your call.
Scan with your smartphone to get the app.
Call us at (888) 365-1663 or visit us at www.consultmdlive.com
Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for 27 abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/terms-of-use/ 010113
CIGNA
Dental
YOUR BENEFITS PACKAGE
About this Benefit Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, treatment and dental disease.
Good dental care may improve your overall health. Also Women with gum disease may be at greater risk of giving birth to a preterm or low birth weight baby.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 28 details on covered expenses, limitations and exclusions included in the summary plan description located on the Mansfield ISD Benefits Website:are www.mybenefitshub.com/mansfieldisd Mansfield ISD Benefits Website: www.mybenefitshub.com/mansfieldisd
Dental PPO - High Plan (Buy Up Plan) This material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plan documents to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusions and limitations.
Cigna Dental Choice Plan Network Options
Reimbursement Levels Policy Year Benefits Maximum Applies to: Class I, II, III, & IX expenses
12 Pay Rates
In-Network: Total Cigna DPPO Network
Out-of-Network: See Non-Network Reimbursement
Based on Contracted Fees
Maximum Reimbursable Charge
$1,250
$1,250
$50 $150
$50 $150
EE Only
$40.22
EE + Spouse
$79.85
EE + Child(ren)
$81.26
Family Coverage
$121.22
Policy Year Deductible Individual Family
Benefit Highlights Class I: Diagnostic & Preventive Oral Evaluations Prophylaxis: routine cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic Emergency Care to Relieve Pain
Class II: Basic Restorative Restorative: fillings Oral Surgery: Simple Extractions Only Anesthesia: general and IV sedation Repairs: Bridges, Crowns and Inlays Repairs: Dentures Crowns: prefabricated stainless steel / resin
Class III: Major Restorative Oral Surgery: All except simple extractions Endodontics: minor and major Periodontics: minor and major Inlays and Onlays Prosthesis Over Implant Crowns: permanent cast and porcelain Bridges and Dentures Denture Relines, Rebases and Adjustments
Class IV: Orthodontia Coverage for Employee and All Dependents
18 Pay Rates
Plan Pays
You Pay
Plan Pays
You Pay
100% No Deductible
No Charge
100% No Deductible
No Charge
EE Only
$26.81
EE + Spouse
$53.23
EE + Child(ren)
$54.17
Family Coverage
$80.81
26 Pay Rates
80% After Deductible
20% After Deductible
80% 20% After Deductible After Deductible
50% After Deductible
50% After Deductible
50% 50% After Deductible After Deductible
50% 50% 50% No Deductible No Deductible No Deductible
EE Only
$18.56
EE + Spouse
$36.85
EE + Child(ren)
$37.50
Family Coverage
$55.95
50% No Deductible
Lifetime Benefits Maximum: $1,250
Class IX: Implants
50% After Deductible
50% After Deductible
50% 50% After Deductible After Deductible
29
Dental PPO - Low Plan (Base Plan) This material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plan documents to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusions and limitations.
Cigna Dental Choice Plan Network Options
Reimbursement Levels Policy Year Benefits Maximum
12 Pay Rates
In-Network: Total Cigna DPPO Network
Out-of-Network: See Non-Network Reimbursement
Based on Contracted Fees
Maximum Allowable Charge
$1,250
$1,250
$50 $150
$50 $150
Applies to: Class I, II, III, & IX expenses
EE Only
$25.67
EE + Spouse
$50.97
EE + Child(ren)
$51.87
Family Coverage
$77.38
Policy Year Deductible Individual Family
Benefit Highlights Class I: Diagnostic & Preventive Oral Evaluations Prophylaxis: routine cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic Emergency Care to Relieve Pain
18 Pay Rates
Plan Pays
You Pay
Plan Pays
You Pay
100% No Deductible
No Charge
100% No Deductible
No Charge
80% 20% 80% 20% After Deductible After Deductible After Deductible After Restorative: fillings Deductible Oral Surgery: Simple Extractions Only Anesthesia: general and IV sedation Repairs: Bridges, Crowns and Inlays Repairs: Dentures Crowns: prefabricated stainless steel / resin 50% 50% 50% 50% Class III: Major Restorative After Deductible After Deductible After Deductible After Oral Surgery: All except simple Deductible extractions Endodontics: minor and major Periodontics: minor and major Inlays and Onlays Prosthesis Over Implant Crowns: permanent cast and porcelain Bridges and Dentures Denture Relines, Rebases and Adjustments 50% 50% 50% 50% Class IV: Orthodontia No Deductible No Deductible No Deductible No Deductible Coverage for Employee and All Dependents Lifetime Benefits Maximum: $1,000
30
$17.11
EE + Spouse
$33.98
EE + Child(ren)
$34.58
Family Coverage
$51.59
26 Pay Rates
Class II: Basic Restorative
Class IX: Implants
EE Only
50% 50% 50% After Deductible After Deductible After Deductible
50% After Deductible
EE Only
$11.85
EE + Spouse
$23.52
EE + Child(ren)
$23.94
Family Coverage
$35.71
Dental PPO - High and Low Plans Benefit Plan Provisions: In-Network Reimbursement Non-Network Reimbursement
Cross Accumulation
Policy Year Benefits Maximum Policy Year Deductible Late Entrant Limitation Provision Pretreatment Review Alternate Benefit Provision
Oral Health Integration Program (OHIP)
Timely Filing
For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Fee Schedule or Discount Schedule. For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Reimbursable Charge. The MRC is calculated at the 90th percentile of all provider charges in the geographic area. The dentist may balance bill up to their usual fees. All deductibles, plan maximums, and service specific maximums cross accumulate between in and out of network. Benefit frequency limitations are based on the date of service and cross accumulate between in and out of network. The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefit-specific Maximums may also apply. This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit-specific deductibles may also apply. Payment will be reduced by 50% for Class III and IV services for 24 months for eligible members that are allowed to enroll in this plan outside of the designated open enrollment period. This provision does not apply to new hires. Pretreatment review is available on a voluntary basis when dental work in excess of $200 is proposed. When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses. Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer radiation, organ transplants and chronic kidney disease. There’s no additional charge for the program, those who qualify get reimbursed 100% of coinsurance for certain related dental procedures. Eligible customers can also receive guidance on behavioral issues related to oral health and discounts on prescription and non-prescription dental products. Reimbursements under this program are not subject to the plan deductible, but will be applied to and are subject to the plan annual maximum. Discounts on certain prescription and non-prescription dental products are available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire discounted charge. For more information including how to enroll in this program and a complete list of program terms and eligible medical conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. Out of network claims submitted to Cigna after 365 days from date of service will be denied.
Benefit Limitations: Missing Tooth Limitation Oral Evaluations X-rays (routine) X-rays (non-routine) Diagnostic Casts Cleanings Fluoride Application Sealants (per tooth) Space Maintainers Inlays, Crowns, Bridges, Dentures and Partials Denture and Bridge Repairs Denture Adjustments, Rebases and Relines Prosthesis Over Implant
For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise payable until covered for 24 months; thereafter, considered a Class III expense. 2 per policy year Bitewings: 2 per policy year Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 consecutive months Payable only in conjunction with orthodontic workup 2 per policy year, including periodontal maintenance procedures following active therapy 1 per policy year for children under age 14 Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 16 Limited to non-orthodontic treatment for children under age 19 Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges. Reviewed if more than once Covered if more than 6 months after installation 1 every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth colored material on molar crowns or bridges.
Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following: Procedures and services not listed under Benefit Highlights; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and/or third molars; Periodontic: bite registrations; splinting; Prosthodontic: precision or semi-precision attachments; Procedures, appliances or restorations, except full dentures, whose main purpose is to: change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint (TMJ); stabilize periodontally involved teeth; or restore occlusion; Athletic mouth guards; Replacement of a lost or stolen appliance; Services performed primarily for cosmetic reasons; Personalization; Services that are deemed to be medical in nature; Services and supplies received from a hospital; Drugs: prescription drugs Charges in excess of the Maximum Reimbursable Charge. Contracted providers are not obligated to provide discounts on non-covered services and may charge their usual fees. This document provides a summary only. It is not a contract. If there are any differences between this summary and the official plan documents, the terms of the official plan documents will prevail. 31
Dental DHMO •
This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized by Cigna Dental as described in your plan documents. Not all Network Dentists perform all listed services and it is suggested to check with your Network Dentist in advance of receiving services.
•
This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made to a Network Specialty Periodontist or Oral Surgeon. You must verify with the Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna Dental. Prior authorization is not required for specialty referrals for Pediatric, Orthodontic and Endodontic services. You may select a Network Pediatric Dentist for your child under the age of 7 by calling Customer Service at 1.800.Cigna24 to get a list of Network Pediatric Dentists in your area. Coverage for treatment by a Pediatric Dentist ends on your child’s 7th birthday; however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist will provide care upon your child’s 7th birthday.
12 Pay Rates EE Only
$10.62
EE + Spouse
$18.56
EE + Child(ren)
$22.96
Family Coverage
$33.00
18 Pay Rates EE Only
$7.08
•
Procedures listed on the Patient Charge Schedule are subject to the plan limitations and exclusions described in your plan book/certificate of coverage and/or group contract.
EE + Spouse
$12.37
•
All patient charges must correspond to the Patient Charge Schedule in effect on the date the procedure is initiated.
EE + Child(ren)
$15.31
Family Coverage
$22.00
•
The American Dental Association may periodically change CDT Codes or definitions. Different codes may be used to describe these covered procedures.
•
The administration of IV sedation, general anesthesia, and/or nitrous oxide is not covered except as specifically listed on this Patient Charge Schedule. The application of local anesthetic is covered as part of your dental treatment.
26 Pay Rates EE Only
$4.90
EE + Spouse
$8.57
EE + Child(ren)
$10.60
Family Coverage
$15.23
•
Cigna Dental considers infection control and/or sterilization to be incidental to and part of the charges for services provided and not separately chargeable.
•
This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement.
After your enrollment is effective: Call the dental office identified in your Welcome Kit. If you wish to change dental offices, a transfer can be arranged at no charge by calling Cigna Dental at the toll free number listed on your ID card or plan materials. Multiple ways to locate a DHMO Network General Dentist: • Online provider directory at www.Cigna.com • Call the number located on your ID card to: - Use the Dental Office Locator via Speech Recognition - Speak to a Customer Service Representative Code
Procedure Description
Member Pays
Office visit fee (per patient, per office visit in addition to any other applicable patient charges) Office visit fee
$ 5.00
Diagnostic/preventive – Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: Periodic oral evaluations (D0120), comprehensive oral evaluations (D0150), comprehensive periodontal evaluations (D0180), and oral evaluations for patients under 3 years of age (D0145).
Code
Procedure Description
Member Pays
Diagnostic/preventive (cont.) D0145
Oral evaluation for a patient under 3 years of age and counseling with primary caregiver
$0.00
D0150
Comprehensive oral evaluation – New or established patient
$0.00
D0210
X-rays intraoral – Complete series of radiographic images (limit 1 every 3 years)
$0.00
D0240
X-rays intraoral – Occlusal radiographic image
$0.00
D9310
Consultation (diagnostic service provided by dentist or physician other than requesting dentist or physician)
$12.00
D9430
Office visit for observation (During regularly scheduled hours) – No other services performed
$6.00
D0270
X-rays (bitewing) – Single radiographic image
$0.00
D0120
Periodic oral evaluation – Established patient
$0.00
D0330
X-rays (panoramic radiographic image) – (limit 1 every 3 years)
$0.00
D0140
Limited oral evaluation – Problem focused
$0.00
D0431
Oral cancer screening using a special light source
$50.00
32
Dental DHMO Code
Procedure Description
Member Pays
Diagnostic/preventive (cont.)
Procedure Description
Member Pays
Periodontics (cont.)
D1110
Prophylaxis (cleaning) – Adult (limit 2 per calendar year)
$0.00
D1120
Prophylaxis (cleaning) – Child (limit 2 per calendar year)
$0.00
D1206
Topical application of fluoride varnish (limit 2 per calendar year). There is a combined limit of a total of 2 D1206s and/or D1208s per calendar year.
$0.00
Sealant – Per tooth
$12.00
D1351
Code
D4341
Periodontal scaling and root planing – 4 or more teeth per quadrant (limit 4 quadrants per consecutive 12 months)
$50.00
D4342
Periodontal scaling and root planing – 1 to 3 teeth per quadrant (limit 4 quadrants per consecutive 12 months)
$40.00
D4910
Periodontal maintenance (limit 4 per calendar year) (only covered after active periodontal therapy)
$40.00
$70.00
Restorative (fillings, including polishing) D2140
Amalgam – 1 surface, primary or permanent
$0.00
Additional periodontal maintenance procedures (beyond 4 per calendar year)
D2330
Resin-based composite – 1 surface, anterior
$0.00
Periodontal charting for planning treatment of periodontal disease
$0.00
D2390
Resin-based composite crown, anterior
$45.00
Periodontal hygiene instruction
$0.00
Crown and bridge – All charges for crowns and bridges (fixed partial dentures) are per unit (each replacement or supporting tooth equals 1 unit). Coverage for replacement of crowns and bridges is limited to 1 every 5 years.
Prosthetics (removable tooth replacement – dentures) includes up to 4 adjustments within first 6 months after insertion – Replacement limit 1 every 5 years. Characterization is considered an upgrade with maximum additional charge to the member of $200.00 per denture.
For single crowns, retainer (“abutment”) crowns, and pontics: The charges below include the cost of predominantly base metal alloy. You may be charged up to these additional amounts, based on the type of material the dentist uses for your restoration. • No more than $150.00 per tooth for any noble metal alloys, high noble metal alloys, titanium or titanium alloys • No more than $75.00 per tooth for any porcelain fused to metal (only on molar teeth) • Porcelain/ceramic substrate crowns on molar teeth are not covered
D5110
Full upper denture
$225.00
D5120
Full lower denture
$225.00
D5211
Upper partial denture – Resin base (including clasps, rests and teeth)
$225.00
D5212
Lower partial denture – Resin base (including clasps, rests and teeth)
$225.00
D2740
Crown – Porcelain/ceramic substrate
$285.00
D2792
Crown – Full cast noble metal
$260.00
D2722
Crown – Resin with noble metal
$260.00
D2950
Core buildup – Including any pins
$65.00
Endodontics (root canal treatment, excluding final restorations) D3310
Anterior root canal – Permanent tooth (excluding final restoration)
$100.00
D3330
Molar root canal – Permanent tooth (excluding final restoration)
$305.00
Periodontics (treatment of supporting tissues [gum and bone] of the teeth) periodontal regenerative procedures are limited to 1 regenerative procedure per site (or per tooth, if applicable), when covered on the patient charge schedule. The relevant procedure codes are D4263, D4264, D4266 and D4267. Localized delivery of antimicrobial agents is limited to 8 teeth (or 8 sites, if applicable) per 12 consecutive months, when covered on the patient charge schedule. D4211
Gingivectomy or gingivoplasty – 1 to 3 teeth per quadrant
$100.00
D4240
Gingival flap (including root planing) – 4 or more teeth per quadrant
$185.00
Oral surgery (includes routine postoperative treatment) Surgical removal of impacted tooth – Not covered for ages below 15 unless pathology (disease) exists. D7111
Extraction of coronal remnants – Deciduous tooth
$6.00
D7140
Extraction, erupted tooth or exposed root – Elevation and/or forceps removal
$6.00
D7220
Removal of impacted tooth – Soft tissue
$65.00
D7240
Removal of impacted tooth – Completely bony
$110.00
Orthodontics (tooth movement) Orthodontic treatment (maximum benefit of 24 months of interceptive and/or comprehensive treatment. Atypical cases or cases beyond 24 months require an additional payment by the patient.) D8670
Periodic orthodontic treatment visit – As part of contract Children – Up to 19th birthday: 24-month treatment fee Charge per month for 24 months
$1,600.00 $67.00
Adults: 24-month treatment fee Charge per month for 24 months
$2,600.00 $108.00
For full Cigna DHMO Services, Fee Schedule, Limits and Exclusions go to www.mybenefitshub.com/mansfieldisd
33
DAVIS VISION
Vision
YOUR BENEFITS PACKAGE
About this Benefit Vision insurance provides coverage for routine eye examinations and may cover all or part of the costs associated with contact lenses, eyeglasses and vision correction, depending on the plan.
75% of U.S. residents between age 25 and 64 require some sort of vision correction.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 34 details on covered expenses, limitations and exclusions included in the summary plan description located on the Mansfield ISD Benefits Website:are www.mybenefitshub.com/mansfieldisd Mansfield ISD Benefits Website: www.mybenefitshub.com/mansfieldisd
Vision IN-NETWORK BENEFITS Every 12 months, Covered in full after $10 Eye Examination copayment EYEGLASSES Every 12 months, Covered in full Spectacle Lenses For standard single-vision, lined bifocal, or trifocal lenses after $25 copayment
Frames
Every 12 months, Covered in full Any Fashion, Designer or Premier frame from Davis Vision’s Collection1 (value up to $195) OR $150 retail allowance toward any frame from provider, plus 20% off balance2 OR $200 allowance, plus 20% off balance to go toward any frame from a Visionworks family of store locations.6
CONTACT LENSES Every 12 months, Collection Contacts: Covered in full Contact Lens OR Evaluation, Fitting Non Collection Contacts: & Follow Up Care Standard Contacts: Covered in full Specialty Contacts3: $60 allowance with 15% off balance2
Contact Lenses (in lieu of eyeglasses)
Every 12 months, Covered in full Any contact lenses from Davis Vision’s Contact Lens Collection1 OR $150 retail allowance toward provider supplied contact lenses, plus 15% off balance2
ADDITIONAL DISCOUNTED LENS OPTIONS & COATINGS MOST POPULAR OPTIONS Without With Davis Savings based on in-network usage and average retail values.
Scratch-Resistant Coating Polycarbonate Lenses Standard Anti-Reflective (AR) Coating Standard Progressives (no-line bifocal) Photochromic Lenses (i.e. Transitions®, etc.)5
Davis Vision
Vision
$25 $66 $83
$0 4 $0 -$30 $35
$198
$50
$110
$65
EMPLOYEE CONTRIBUTIONS
Monthly Rate
Employee Employee plus Spouse Employee plus Child(ren) Employee plus Family
$6.61 $11.25 $11.93 $17.87
18 Pay Rates
26 Pay Rates
Employee Employee plus Spouse Employee plus Child(ren) Employee plus Family
$4.41 $7.50 $7.95 $11.91
$3.05 $5.19 $5.51 $8.25
ADDITIONAL OPTIONS
Without Davis Vision
With Davis Vision
$100
$0
$160
$0
$195
$0
$90
$0
$78 $20 $25 $25 $66 $25
$0 $0 $0 $0 $01 or $30 $12
$83
$35
$104 $121
$48 $60
$198
$50
$247
$90
$369
$140
$120 $103
$55 $75
$110
$65
FRAMES Fashion Frame (from the Davis Vision Collection) Designer Frame (from the Davis Vision Collection) Premier Frame (from the Davis Vision Collection)
LENSES All Ranges of Prescriptions and Sizes Plastic Lenses Oversized Lenses Tinting of Plastic Lenses Scratch-Resistant Coating Polycarbonate Lenses Ultraviolet Coating Standard Anti-Reflective (AR) Coating Premium AR Coating Ultra AR Coating Standard Progressive Addition Lenses Premium Progressives Addition Lenses Ultra Progressive Addition Lenses High-Index Lenses Polarized Lenses Photochromic Lenses (i.e. Transitions®, etc.)2 Scratch Protection Plan (Single vision | Multifocal lenses)
$20 | $40
OUT-OF-NETWORK BENEFITS
OUT-OF-NETWORK REIMBURSEMENT SCHEDULE
You may receive services from an out-of-network provider, although you will receive the greatest value and maximize your benefit dollars if you select a provider who participates in the network. If you choose an out-of-network provider, you must pay the provider directly for all charges and then submit a claim for reimbursement to: Vision Care Processing Unit P.O. Box 1525 Latham, NY 12110
Eye Examination up to $40 | Frame up to $70 Spectacle Lenses (per pair) up to: Single Vision $40 Bifocal $60 Trifocal $80 Lenticular $100 Elective Contacts up to $105 Visually Required Contacts up to $225
1 The Davis Vision Collection is available at most participating independent provider locations. Collection is subject to change. Collection is inclusive of select toric and multifocal contacts. 2 Additional discounts not applicable at Walmart, Sam’s Club or Costco locations. 3 Including, but not limited to toric, multifocal and gas permeable contact lenses. 4 For dependent children, monocular patients and patients with prescriptions of 6.00 diopters or greater. 5 Transitions® is a registered trademark of Transitions Optical Inc. 6 Enhanced frame allowance available at all Visionworks Locations nationwide.
35
AUL A ONEAMERICA COMPANY YOUR BENEFITS PACKAGE
Disability
About this Benefit Disability insurance protects one of your most valuable assets, your paycheck. This insurance will replace a portion of your income in the event that you become physically unable to work due to sickness or injury for an extended period of time.
Just over 1 in 4 of today's 20 year -olds will become disabled before they retire.
34.6 months is the duration of the average disability claim.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 36 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Mansfield ISD Benefits Website: www.mybenefitshub.com/mansfieldisd
Long Term Disability Eligible Employees This benefit is available for employees who are actively at work on the effective date and working a minimum of 18 hours per week.
Partial Disability
Since everyone's needs are different, these plans offer flexibility for you to choose a benefit option that fits your income replacement needs and budget.
You may be paid a partial disability benefit, if because of injury or sickness, you are unable to perform every material and substantial duty of your regular occupation on a full-time basis, are performing at least one of the material and substantial duties of your regular occupation, or another occupation, on a full or part- time basis, and are earning less than 80% of your predisability earnings due to the same injury or sickness.
Guaranteed Issue
Residual
If you enroll timely, you may be eligible for coverage without having to answer any health questions. If you decline insurance coverage now and decide to enroll later, you will need to provide Evidence of Insurability.
Return to Work
Flexible Choices
Timely Enrollment Enrolling timely means you have enrolled during the initial enrollment period when benefits were first offered by AUL, or as a newly hired employee within 31 days following completion of any applicable waiting period, or during a scheduled enrollment period.
Evidence of Insurability If you do not enroll timely, you will need to submit a Statement of Insurability form for review. Based on health history, you will be approved or declined by AUL .
Waiver of Premium If approved, this benefit waives your Disability insurance premium in case you become disabled and are unable to collect a paycheck.
Elimination Period This is a period of consecutive days of disability before benefits may become payable under the contract
The elimination period can be satisfied by total disability, partial disability, or a combination of both.
You may be able to return to work for a specified time period without having your partial disability benefits reduced according to the contract. The Return to Work Benefit is offered up to a maximum of 12 months.
Integration The method by which your benefit may be reduced by Other Income Benefits.
Pre-Existing Condition Limitations The pre-existing period is 3/12. Certain disabilities are not covered if the cause of the disability is traceable to a condition existing prior to your effective date of coverage. A pre-existing condition is any condition for which a person has received medical treatment or consultation, taken or were prescribed drugs or medicine, or received care or services, including diagnostic measures, within a time-frame specified in the contract. You must also be treatment-free for a time-frame specified in some contracts following your individual effective date of coverage .
Total Disability You are considered disabled if, because of injury or sickness, you cannot perform the material and substantial duties of your regular occupation, you are not working in any occupation and are under the regular attendance of a physician for that injury or sickness.
37
Long Term Disability Group Educator Disability Insurance Coverage for Eligible Employees Monthly Payroll Deduction Illustration About your benefit options: • • •
Group Educator Disability benefits are illustrated and paid on a monthly basis. Amounts not requested timely will require Evidence of Insurability. Maximum benefit amounts are based upon a percentage of covered earnings. Potential benefits are reduced by other income offsets including but not limited to Social Security benefits.
If your Annual Salary is at least:
You may select a Monthly Benefit of:
Opt 1 0/7
Opt 2 14/14
Opt 3 30/30
Opt 4 60/60
Opt 5 90/90
Opt 6 180/180
$3,600
$200
$6.00
$5.12
$4.40
$3.48
$1.96
$1.40
$5,400
$300
$9.00
$7.68
$6.60
$5.22
$2.94
$2.10
$7,200
$400
$12.00
$10.24
$8.80
$6.96
$3.92
$2.80
$9,000
$500
$15.00
$12.80
$11.00
$8.70
$4.90
$3.50
$10,799
$600
$18.00
$15.36
$13.20
$10.44
$5.88
$4.20
$12,599
$700
$21.00
$17.92
$15.40
$12.18
$6.86
$4.90
$14,399
$800
$24.00
$20.48
$17.60
$13.92
$7.84
$5.60
$16,199
$900
$27.00
$23.04
$19.80
$15.66
$8.82
$6.30
$17,999
$1,000
$30.00
$25.60
$22.00
$17.40
$9.80
$7.00
$19,799
$1,100
$33.00
$28.16
$24.20
$19.14
$10.78
$7.70
$21,599
$1,200
$36.00
$30.72
$26.40
$20.88
$11.76
$8.40
$23,399
$1,300
$39.00
$33.28
$28.60
$22.62
$12.74
$9.10
$25,199
$1,400
$42.00
$35.84
$30.80
$24.36
$13.72
$9.80
$26,999
$1,500
$45.00
$38.40
$33.00
$26.10
$14.70
$10.50
$28,799
$1,600
$48.00
$40.96
$35.20
$27.84
$15.68
$11.20
$30,598
$1,700
$51.00
$43.52
$37.40
$29.58
$16.66
$11.90
$32,398
$1,800
$54.00
$46.08
$39.60
$31.32
$17.64
$12.60
$34,198
$1,900
$57.00
$48.64
$41.80
$33.06
$18.62
$13.30
$35,998
$2,000
$60.00
$51.20
$44.00
$34.80
$19.60
$14.00
$37,798
$2,100
$63.00
$53.76
$46.20
$36.54
$20.58
$14.70
$39,598
$2,200
$66.00
$56.32
$48.40
$38.28
$21.56
$15.40
$41,398
$2,300
$69.00
$58.88
$50.60
$40.02
$22.54
$16.10
$43,198
$2,400
$72.00
$61.44
$52.80
$41.76
$23.52
$16.80
$44,998
$2,500
$75.00
$64.00
$55.00
$43.50
$24.50
$17.50
$46,798
$2,600
$78.00
$66.56
$57.20
$45.24
$25.48
$18.20
$48,598
$2,700
$81.00
$69.12
$59.40
$46.98
$26.46
$18.90
$50,397
$2,800
$84.00
$71.68
$61.60
$48.72
$27.44
$19.60
$52,197 38
$2,900
$87.00
$74.24
$63.80
$50.46
$28.42
$20.30
Monthly Payroll Deduction Amounts
Long Term Disability If your Annual Salary is at least:
You may select a Monthly Benefit of:
Opt 1 0/7
Opt 2 14/14
Opt 3 30/30
Opt 4 60/60
Opt 5 90/90
Opt 6 180/180
$53,997
$3,000
$90.00
$76.80
$66.00
$52.20
$29.40
$21.00
$55,797
$3,100
$93.00
$79.36
$68.20
$53.94
$30.38
$21.70
$57,597
$3,200
$96.00
$81.92
$70.40
$55.68
$31.36
$22.40
$59,397
$3,300
$99.00
$84.48
$72.60
$57.42
$32.34
$23.10
$61,197
$3,400
$102.00
$87.04
$74.80
$59.16
$33.32
$23.80
$62,997
$3,500
$105.00
$89.60
$77.00
$60.90
$34.30
$24.50
$64,797
$3,600
$108.00
$92.16
$79.20
$62.64
$35.28
$25.20
$66,597
$3,700
$111.00
$94.72
$81.40
$64.38
$36.26
$25.90
$68,397
$3,800
$114.00
$97.28
$83.60
$66.12
$37.24
$26.60
$70,196
$3,900
$117.00
$99.84
$85.80
$67.86
$38.22
$27.30
$71,996
$4,000
$120.00
$102.40
$88.00
$69.60
$39.20
$28.00
$73,796
$4,100
$123.00
$104.96
$90.20
$71.34
$40.18
$28.70
$75,596
$4,200
$126.00
$107.52
$92.40
$73.08
$41.16
$29.40
$77,396
$4,300
$129.00
$110.08
$94.60
$74.82
$42.14
$30.10
$79,196
$4,400
$132.00
$112.64
$96.80
$76.56
$43.12
$30.80
$80,996
$4,500
$135.00
$115.20
$99.00
$78.30
$44.10
$31.50
$82,796
$4,600
$138.00
$117.76
$101.20
$80.04
$45.08
$32.20
$84,596
$4,700
$141.00
$120.32
$103.40
$81.78
$46.06
$32.90
$86,396
$4,800
$144.00
$122.88
$105.60
$83.52
$47.04
$33.60
$88,196
$4,900
$147.00
$125.44
$107.80
$85.26
$48.02
$34.30
$89,996
$5,000
$150.00
$128.00
$110.00
$87.00
$49.00
$35.00
$91,795
$5,100
$153.00
$130.56
$112.20
$88.74
$49.98
$35.70
$93,595
$5,200
$156.00
$133.12
$114.40
$90.48
$50.96
$36.40
$95,395
$5,300
$159.00
$135.68
$116.60
$92.22
$51.94
$37.10
$97,195
$5,400
$162.00
$138.24
$118.80
$93.96
$52.92
$37.80
$98,995
$5,500
$165.00
$140.80
$121.00
$95.70
$53.90
$38.50
$100,795
$5,600
$168.00
$143.36
$123.20
$97.44
$54.88
$39.20
$102,595
$5,700
$171.00
$145.92
$125.40
$99.18
$55.86
$39.90
$104,395
$5,800
$174.00
$148.48
$127.60
$100.92
$56.84
$40.60
$106,195
$5,900
$177.00
$151.04
$129.80
$102.66
$57.82
$41.30
$107,995
$6,000
$180.00
$153.60
$132.00
$104.40
$58.80
$42.00
$109,795
$6,100
$183.00
$156.16
$134.20
$106.14
$59.78
$42.70
$111,594
$6,200
$186.00
$158.72
$136.40
$107.88
$60.76
$43.40
$113,394
$6,300
$189.00
$161.28
$138.60
$109.62
$61.74
$44.10
$115,194
$6,400
$192.00
$163.84
$140.80
$111.36
$62.72
$44.80 39
Monthly Payroll Deduction Amounts
AUL A ONEAMERICA COMPANY
Life and AD&D
YOUR BENEFITS PACKAGE
About this Benefit Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family. Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.
Motor vehicle crashes are the
#1
cause of accidental deaths in the US, followed by poisoning, falls, drowning, and choking.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 40 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Mansfield ISD Benefits Website: www.mybenefitshub.com/mansfieldisd
Life and AD&D Group Term Life Including matching AD&D Coverage • • • • •
Life and AD&D insurance coverage amount of $10,000 at no cost to you Waiver of premium benefit Accelerated life benefit Additional AD&D Benefits: Seat Belt, Air Bag, Repatriation, Child Higher Education, Child Care, Paralysis/Loss of Use, Severe Burns Optional Guaranteed issue amounts of dependent coverage as follows:
Eligible Employees This benefit is available for employees who are actively at work on the effective date and working a minimum of 18 hours per week.
Flexible Choices Since everyone's needs are different, this plan offers flexibility for you to choose a benefit amount that fits your needs and budget.
Accidental Death & Dismemberment (AD&D) If approved for this benefit, additional life insurance benefits may be payable in the event of an accident which results in death or dismemberment as defined in the contract.
Guaranteed Issue Amounts This is the most coverage you can purchase without having to answer any health questions. If you decline insurance coverage now and decide to enroll later, you will need to provide Evidence of Insurability. Employee Guaranteed Issue Amount: $200,000 Spouse Guaranteed Issue Amount: $50,000 Child Guaranteed Issue Amount: $10,000
Continuation of Coverage Options Portability Should your coverage terminate for any reason, you may be eligible to take this term life insurance with you without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible. The Portability option is available until you reach age 70. OR Conversion Should your life insurance coverage, or a portion of it, cease for any reason, you may be eligible to convert your Group Term Coverage to Individual Coverage without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible.
Accelerated Life Benefit If diagnosed with a terminal illness and have less than 12 months to live, you may apply to receive 25%, 50% or 75% of your life insurance benefit to use for whatever you choose.
Waiver of Premium If approved, this benefit waives your insurance premium in case you become totally disabled and are unable to collect a paycheck.
Reductions Upon reaching certain ages, your original benefit amount will reduce to a percentage as shown in the following schedule. The amounts of Dependent Life Insurance and Dependent AD&D Principal Sum will reduce according to the Employee's reduction schedule. Age 70 Reduces to: 65% Age 75 Reduces to: 50%
Timely Enrollment Enrolling timely means you have enrolled during the initial enrollment period when benefits were first offered by AUL, or as a newly hired employee within 31 days following completion of any applicable waiting period.
Evidence of Insurability If you elect a benefit amount over the Guaranteed Issue Amount shown above, or you do not enroll timely, you will need to submit a Statement of Insurability form for review. Based on health history, you will be approved or declined for insurance coverage by AUL. 41
Life and AD&D Voluntary Term Life Coverage Monthly Payroll Deduction Illustration About your benefit options: • • • •
You may select a minimum Life benefit of $10,000 up to a maximum amount of $500,000, in increments of $10,000. Life amounts requested above $200,000 for an Employee, $50,000 for a Spouse, or any amount not requested timely will require Evidence of Insurability. Employee must select coverage to select any Dependent coverage. Dependent coverage cannot exceed 100% of the Voluntary Term Life amount selected by the Employee.
EMPLOYEE ONLY OPTIONS (based on Employee's age as of 09/01) Life & AD&D
0-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
$10,000
$.40
$.40
$.40
$.56
$.64
$.72
$1.12
$1.68
$3.12
$4.72
$9.12
$14.80
$18.40
$20,000
$.80
$.80
$.80
$1.12
$1.28
$1.44
$2.24
$3.36
$6.24
$9.44
$18.24
$29.60
$36.80
$30,000
$1.20
$1.20
$1.20
$1.68
$1.92
$2.16
$3.36
$5.04
$9.36
$14.16
$27.36
$44.40
$55.20
$40,000
$1.60
$1.60
$1.60
$2.24
$2.56
$2.88
$4.48
$6.72
$12.48
$18.88
$36.48
$59.20
$73.60
$50,000
$2.00
$2.00
$2.00
$2.80
$3.20
$3.60
$5.60
$8.40
$15.60
$23.60
$45.60
$74.00
$92.00
$80,000
$3.20
$3.20
$3.20
$4.48
$5.12
$5.76
$8.96
$13.44
$24.96
$37.76
$72.96 $118.40 $147.20
$100,000
$4.00
$4.00
$4.00
$5.60
$6.40
$7.20
$11.20
$16.80
$31.20
$47.20
$91.20 $148.00 $184.00
$130,000
$5.20
$5.20
$5.20
$7.28
$8.32
$9.36
$14.56
$21.84
$40.56
$61.36 $118.56 $192.40 $239.20
$150,000
$6.00
$6.00
$6.00
$8.40
$9.60
$10.80 $16.80
$25.20
$46.80
$70.80 $136.80 $222.00 $276.00
$200,000
$8.00
$8.00
$8.00
$11.20 $12.80 $14.40 $22.40
$33.60
$62.40
$94.40 $182.40 $296.00 $368.00
SPOUSE ONLY OPTIONS (based on Employee's Age as of 09/01 Life Options
0-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
$10,000
$.40
$.40
$.40
$.56
$.64
$.72
$1.12
$1.68
$3.12
$4.72
$9.12
$14.80
$18.40
$15,000
$.60
$.60
$.60
$.84
$.96
$1.08
$1.68
$2.52
$4.68
$7.08
$13.68
$22.20
$27.60
$20,000
$.80
$.80
$.80
$1.12
$1.28
$1.44
$2.24
$3.36
$6.24
$9.44
$18.24
$29.60
$36.80
$25,000
$1.00
$1.00
$1.00
$1.40
$1.60
$1.80
$2.80
$4.20
$7.80
$11.80
$22.80
$37.00
$46.00
$30,000
$1.20
$1.20
$1.20
$1.68
$1.92
$2.16
$3.36
$5.04
$9.36
$14.16
$27.36
$44.40
$55.20
$35,000
$1.40
$1.40
$1.40
$1.96
$2.24
$2.52
$3.92
$5.88
$10.92
$16.52
$31.92
$51.80
$64.40
$40,000
$1.60
$1.60
$1.60
$2.24
$2.56
$2.88
$4.48
$6.72
$12.48
$18.88
$36.48
$59.20
$73.60
$45,000
$1.80
$1.80
$1.80
$2.52
$2.88
$3.24
$5.04
$7.56
$14.04
$21.24
$41.04
$66.60
$82.80
$50,000
$2.00
$2.00
$2.00
$2.80
$3.20
$3.60
$5.60
$8.40
$15.60
$23.60
$45.60
$74.00
$92.00
42
Life and AD&D CHILD(REN) OPTIONS (Premium shown for Child(ren) reflects the cost for all eligible dependent children) Child(ren) 6 months to age 26 Option 1:
Child(ren) live birth to 6 months
$10,000
Monthly Payroll Deduction Life Amount
$1,000
$1.80
About Premiums: The premiums shown above may vary slightly due to rounding; actual premiums will be calculated by American United Life Insurance Company® (AUL), and may increase upon reaching certain age brackets, according to contract terms, and are subject to change.
Voluntary Term AD&D Coverage Monthly Payroll Deduction Illustration About your benefit options: • • •
You may select a minimum benefit of $10,000 up to a maximum amount of $500,000, in increments of $10,000. Employee must select coverage to select any Dependent coverage. The Spouse benefit is equal to 50% of the amount elected by the Employee, the Child benefit is equal to 10% of the amount elected by the Employee.
Employee Only AD&D
Family AD&D
Volume
Monthly Deduction
Employee Volume
Spouse Volume
Child Volume
Monthly Deduction
$10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000
$0.300 $0.600 $0.900 $1.200 $1.500 $1.800 $2.100 $2.400 $2.700 $3.000 $4.500 $6.000 $7.500 $9.000 $10.500 $12.000 $13.500 $15.000
$10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000
$5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000
$1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000
$0.600 $1.200 $1.800 $2.400 $3.000 $3.600 $4.200 $4.800 $5.400 $6.000 $9.000 $12.000 $15.000 $18.000 $21.000 $24.000 $27.000 $30.000
43
5STAR
Individual Life
About this Benefit Group termlife lifeis isa policy the most to Individual thatinexpensive provides a way specified purchase life insurance. You have at thethe freedom death benefit to your beneficiary time ofto select amount of lifeofinsurance death.an The advantage having ancoverage individualyou lifeneed to help protect theopposed well-being your family. insurance plan as to aofgroup supplemental term life plan is that this plan is guaranteed renewable, portable and typically premiums remain the same over the life of the policy.
YOUR BENEFITS PACKAGE
Experts recommend at least
x 10 your gross annual income in coverage when purchasing life insurance.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 44 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Mansfield ISD Benefits Website: www.mybenefitshub.com/mansfieldisd
Term Life with Terminal Illness and Quality of Life Rider The Family Protection Plan: Individual Life Insurance with Terminal Illness Coverage to Age 100 With the Family Protection Plan (FPP), you can provide financial stability for your loved ones should something happen to you. You have peace of mind that you are covered up to age 100.* No matter what the future brings, you and your family will be protected. If faced with a chronic medical condition that required continuous care, would you be able to protect yourself? Traditionally, expenses associated with treatment and care necessitated by a chronic injury or illness have accounted for 86% of all health care spending and can place strain on your assets when you need them most. To provide protection during this time of need, 5Star Life Insurance Company (5Star Life) is pleased to offer the Quality of Life Rider, which is included with your FPP life insurance coverage. This rider accelerates a portion of the death benefit on a monthly basis—4% each month as scheduled by your employer at the group level, and payable directly to you on a tax favored basis. You can receive up to 75% of the current face amount of the life benefit, following a diagnosis of either a chronic illness or cognitive impairment that requires substantial assistance. Benefits are paid for the following: • Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance, or • A permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility requiring substantial supervision. Example
Weekly Premium
Death Benefit
Accelerated Benefit
Your age at issue: 35
$10.00
$89,655
4% $3,586.20 a month
Affordability—With several options to choose from, select the coverage that best meets the needs of your family. Terminal Illness—This plan pays the insured 30% (25% in Connecticut and Michigan) of the policy coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months. Portability—You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. If this happens, we can simply bill you directly. Coverage can never be cancelled by the insurance company or your employer unless you stop paying premiums. Family Protection—Individual policies can be purchased on the employee, their spouse, children and grandchildren. Children & Grandchildren Plan—Policies can be purchased for children and grandchildren ages 15 days to age 24. Convenience—Premiums are taken care of simply and easily through payroll deductions. Protection You Can Count On—Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the two-year contestability period and/or under investigation. This product also contains no war or terrorism exclusions.
For example, in case of chronic illness, you would receive $3,586 each month up to $67,241.25. The remainder death benefit of $22,413.75 would be made payable to your beneficiary.
* Life insurance product underwritten by 5Star Life Insurance Company (a Baton Rouge, Louisiana company). Product may not be available in all states or territories. Request FPP insurance from Dell Perot, Post Office Box 83043, Lincoln, Nebraska 68501, (866) 863-9753.
45
Term Life with Terminal Illness and Quality of Life Rider MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT
18-25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
$10,000 $7.56 $7.59 $7.65 $7.74 $7.88 $8.07 $8.27 $8.50 $8.73 $9.01 $9.30 $9.64 $10.02 $10.41 $10.85 $11.31 $11.83 $12.41 $13.00 $13.63 $14.27
$20,000 $10.78 $10.83 $10.97 $11.15 $11.43 $11.80 $12.20 $12.65 $13.11 $13.67 $14.27 $14.95 $15.70 $16.48 $17.35 $18.29 $19.33 $20.48 $21.66 $22.91 $24.22
$30,000 $14.01 $14.09 $14.28 $14.56 $14.99 $15.53 $16.14 $16.81 $17.51 $18.34 $19.23 $20.26 $21.39 $22.56 $23.86 $25.26 $26.83 $28.56 $30.34 $32.21 $34.16
Employee Coverage Amounts $40,000 $50,000 $75,000 $17.24 $20.46 $28.53 $17.33 $20.59 $28.71 $17.60 $20.92 $29.21 $17.96 $21.38 $29.90 $18.54 $22.09 $30.96 $19.27 $23.00 $32.34 $20.06 $24.00 $33.84 $20.97 $25.12 $35.52 $21.90 $26.29 $37.27 $23.00 $27.67 $39.33 $24.20 $29.17 $41.59 $25.57 $30.88 $44.15 $27.07 $32.76 $46.96 $28.64 $34.71 $49.89 $30.37 $36.87 $53.15 $32.23 $39.21 $56.65 $34.33 $41.83 $60.58 $36.63 $44.71 $64.90 $39.00 $47.67 $69.33 $41.50 $50.79 $74.02 $44.10 $54.05 $78.90
46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
$14.97 $15.70 $16.43 $17.22 $18.08 $19.04 $20.16 $21.40 $22.79 $24.26 $25.94 $27.66 $29.42 $31.23 $33.12 $35.08 $37.12 $39.31 $41.68 $44.34
$25.60 $27.05 $28.51 $30.10 $31.82 $33.75 $35.98 $38.46 $41.25 $44.20 $47.53 $50.98 $54.50 $58.12 $61.90 $65.82 $69.91 $74.29 $79.04 $84.33
$36.24 $38.41 $40.61 $42.98 $45.56 $48.46 $51.81 $55.54 $59.71 $64.13 $69.14 $74.31 $79.58 $85.01 $90.69 $96.56 $102.71 $109.26 $116.38 $124.34
$46.87 $49.77 $52.70 $55.87 $59.30 $63.17 $67.63 $72.60 $78.17 $84.06 $90.73 $97.63 $104.67 $111.90 $119.46 $127.30 $135.50 $144.23 $153.73 $164.33
Age on Eff. Date
46
$57.51 $61.13 $64.79 $68.75 $73.04 $77.88 $83.46 $89.67 $96.63 $104.00 $112.34 $120.96 $129.75 $138.79 $148.25 $158.04 $168.29 $179.21 $191.09 $204.34
$84.09 $89.52 $95.03 $100.96 $107.39 $114.65 $123.02 $132.33 $142.77 $153.83 $166.33 $179.27 $192.46 $206.02 $220.21 $234.90 $250.27 $266.65 $284.46 $304.33
$100,000 $36.59 $36.83 $37.50 $38.41 $39.84 $41.67 $43.66 $45.92 $48.25 $51.00 $54.00 $57.42 $61.17 $65.09 $69.42 $74.08 $79.33 $85.08 $91.00 $97.25 $103.75
$125,000 $44.65 $44.96 $45.80 $46.94 $48.71 $51.01 $53.50 $56.31 $59.23 $62.67 $66.42 $70.69 $75.37 $80.27 $85.68 $91.52 $98.08 $105.27 $112.67 $120.48 $128.60
$150,000 $52.71 $53.09 $54.08 $55.46 $57.59 $60.33 $63.34 $66.71 $70.21 $74.34 $78.83 $83.96 $89.59 $95.46 $101.96 $108.96 $116.83 $125.46 $134.34 $143.71 $153.46
$110.67 $117.92 $125.25 $133.17 $141.75 $151.42 $162.58 $175.00 $188.92 $203.66 $220.33 $237.58 $255.17 $273.25 $292.16 $311.75 $332.25 $354.08 $377.83 $404.33
$137.25 $146.32 $155.48 $165.37 $176.10 $188.19 $202.15 $217.67 $235.07 $253.50 $274.34 $295.89 $317.87 $340.48 $364.13 $388.60 $414.23 $441.52 $471.21 $504.34
$163.84 $174.71 $185.71 $197.58 $210.46 $224.96 $241.71 $260.34 $281.21 $303.33 $328.34 $354.21 $380.58 $407.71 $436.09 $465.46 $496.21 $528.96 $564.58 $604.34
Term Life with Terminal Illness and Quality of Life Rider MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Age on Eff. Date 66* 67* 68* 69* 70*
$10,000 $44.93 $48.25 $52.03 $56.33 $61.17
$20,000 $85.52 $92.17 $99.73 $108.32 $118.00
$30,000 $126.11 $136.08 $147.43 $160.31 $174.83
Employee Coverage Amounts $40,000 $50,000 $75,000 $166.70 $207.29 $308.77 $180.00 $223.92 $333.71 $195.13 $242.83 $362.08 $212.30 $264.29 $394.27 $231.67 $288.50 $430.58
$100,000 $410.25 $443.50 $481.33 $524.25 $572.67
$125,000 $511.73 $553.29 $600.58 $654.23 $714.75
$150,000 $613.21 $663.08 $719.83 $784.21 $856.83
*Quality of Life not available ages 66 - 70. Quality of Life benefits not available for children. Child life coverage available only on children and grandchildren of employee (age on effective date: age 14 days through 23 years). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.
47
AMERICAN PUBLIC LIFE
Cancer
About this Benefit Cancer insurance offers you and your family supplemental insurance protection in the event you or a covered family member is diagnosed with cancer. It pays a benefit directly to you to help with expenses associated with cancer treatment.
YOUR BENEFITS PACKAGE
Breast Cancer is the most commonly diagnosed cancer in women.
If caught early, prostate cancer is one of the most treatable malignancies.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 48 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Mansfield ISD Benefits Website: www.mybenefitshub.com/mansfieldisd
GC14 Limited Benefit Group Cancer Indemnity Insurance Mansfield ISD THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NONSUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.
Summary of Benefits
Plan 1
Plan 2
Cancer Treatment Policy Benefits
Level 1
Level 4
Radiation Therapy, Chemotherapy, Immunotherapy - Maximum per 12-month period Hormone Therapy - Maximum of 12 treatments per calendar year
$10,000
$20,000
$50 per treatment
$50 per treatment
Experimental Treatment
paid in same manner and under the same maximums as any other benefit Level 1 Level 1
Cancer Screening Rider Benefits Diagnostic Testing - 1 test per calendar year
$50 per test
$50 per test
Follow-Up Diagnostic Testing - 1 test per calendar year
$100 per test
$100 per test
Medical Imaging - 1 test per calendar year
$500 per test
$500 per test
Internal Cancer First Occurrence Rider Benefits
Level 2
Level 4
Lump Sum Benefit - Maximum 1 per Covered Person per lifetime
$5,000
$10,000
Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime
$7,500
$15,000
Heart Attack/Stroke First Occurrence Rider Benefits
Level 2
Level 4
Lump Sum Benefit - Maximum 1 per Covered Person per lifetime
$5,000
$10,000
Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime
$7,500
$15,000
$600 per day $300 per day
$600 per day $300 per day
Hospital Intensive Care Unit Benefit Rider Intensive Care Unit Step Down Unit - Maximum of 45 days per Confinement for any combination of Intensive Care Unit or Step Down Unit
Total Monthly Premiums by Plan** Issue Ages 18 +
Employee
Employee & Spouse
Employee & Child(ren)
Employee & Family
Plan 1
Plan 2
Plan 1
Plan 2
Plan 1
Plan 2
Plan 1
Plan 2
$15.96
$26.80
$34.26
$57.60
$20.38
$33.00
$38.66
$63.84
**Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application.
49
APSB-22339(TX)-0615 MGM/FBS Mansfield ISD
GC14 Limited Benefit Group Cancer Indemnity Insurance Benefits are only payable following a diagnosis of cancer for a loss incurred for the treatment of cancer while covered under the policy. A charge must be incurred for benefits to be payable. When coverage terminates for loss incurred after the coverage termination date, our obligation to pay benefits also terminates for a specified disease that manifested itself while the person was covered under the policy. All benefits are subject to the benefit maximums.
Cancer Treatment Benefits Eligibility
You and your eligible dependents are eligible to be insured under this certificate if you and your eligible dependents meet our underwriting rules and you are actively at work with the policyholder and qualify for coverage as defined in the master application.
Cancer Screening Benefits Limitations and Exclusions
No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition. For the purpose of benefits under this rider, the waiting period will begin on the covered person’s effective date of this rider.
Termination of Cancer Screening Benefit Rider
No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; or losses or medical expenses incurred prior to the covered person’s effective date regardless of when specified disease was diagnosed.
The above listed rider(s) will terminate and coverage will end for all covered persons on the earliest of: the end of the grace period if the premium for the rider remains unpaid; the date the policy or certificate to which the rider is attached terminates; the end of the certificate month in which APL receives a request from the policyholder to terminate the rider; or the date of your death. Coverage on an eligible dependent terminates under the rider when such person ceases to meet the definition of eligible dependent.
Only Loss for Cancer
Internal Cancer First Occurrence Benefits
Limitations and Exclusions
The policy pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. The policy also covers other conditions or diseases directly caused by cancer or the treatment of cancer. The policy does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment of cancer.
Pre-Existing Condition Exclusion
No benefits are payable for any loss incurred during the pre-existing condition exclusion period, following the covered person’s effective date as the result of a pre-existing condition. Pre-existing conditions specifically named or described as excluded in any part of the policy are never covered. If any change to coverage after the certificate effective date results in an increase or addition to coverage, the time limit on certain defenses and pre-existing condition exclusion for such increase will be based on the effective date of such increase.
Waiting Period
The policy and any attached riders contain a waiting period during which no benefits will be paid. If any covered person has a specified disease diagnosed before the end of the waiting period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the covered person’s effective date. If any covered person is diagnosed as having a specified disease during the waiting period immediately following the covered person’s effective date, you may elect to void the certificate from the beginning and receive a full refund of premium. If the policy replaced group specified disease cancer coverage from any company that terminated within 30 days of the certificate effective date, the waiting period will be waived for those covered persons that were covered under the prior coverage. However, the pre-existing condition exclusion provision will still apply.
Termination of Certificate
Pays a lump sum benefit amount when a covered person receives a first diagnosis of internal cancer and the date of diagnosis occurs after the waiting period. Only one benefit per covered person, per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.
Limitations and Exclusions
We will not pay benefits for a diagnosis of internal cancer received outside the territorial limits of the United States or a metastasis to a new site of any cancer diagnosed prior to the covered person’s effective date, as this is not considered a first diagnosis of an internal cancer.
Pre-Existing Condition Exclusion
No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a pre-existing condition.
Waiting Period
This rider contains a 30-day waiting period during which no benefits will be paid. If any internal cancer is diagnosed before the end of the waiting period immediately following the covered person’s effective date of this rider, coverage will apply only to loss that is incurred after one year from the covered person’s effective date of this rider.
Termination
This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of covered person’s death or the date the lump sum benefit amount for internal cancer has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.
Heart Attack/Stroke First Occurrence Benefits
Insurance coverage under the certificate and any attached riders will end on the earliest of these dates: the date the policy terminates; the end of the grace period if the premium remains unpaid; the date insurance has ceased on all persons covered under this certificate; the end of the certificate month in which the policyholder requests to terminate this coverage; the date you no longer qualify as an insured; or the date of your death.
Pays a lump sum benefit amount when a covered person receives a first diagnosis of heart attack or stroke and the date of diagnosis occurs after the waiting period. Only one benefit per covered person per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.
Termination of Coverage
Limitations and Exclusions
Insurance coverage for a covered person under the certificate and any attached riders for a covered person will end as follows: the date the policy terminates; the date the certificate terminates; the end of the grace period if the premium remains unpaid; the end of the certificate month in which the policyholder requests to terminate the coverage for an eligible dependent; the date a covered person no longer qualifies as an insured or eligible dependent; or the date of the covered person’s death. We may end the coverage of any Covered Person who submits a fraudulent claim.
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APSB-22339(TX)-0615 MGM/FBS Mansfield ISD
We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in the armed forces, or military service for any country at war [(if coverage is suspended for any covered person during a period of military service, we will refund the pro-rata portion of any premium paid for any such covered person upon receipt of the policyholder’s written request)]; participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; or participation in, or attempting to participate in, a felony, riot or insurrection (a felony is defined by the law of the jurisdiction in which the activity takes place).
GC14 Limited Benefit Group Cancer Indemnity Insurance Pre-Existing Condition Exclusion
Optionally Renewable
Waiting Period
This policy/riders are optionally renewable. The policyholder or we have the right to terminate the policy/riders on any premium due date after the first anniversary following the policy/riders effective date. We must give at least 60 days written notice to the policyholder prior to cancellation.
No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a Pre-Existing Condition. This rider contains a 30-day waiting period during which no benefits will be paid. If any heart attack or stroke is diagnosed before the end of the waiting period immediately following the covered person’s effective date of this rider, coverage will apply only to loss that is incurred after one year from the covered person’s effective date.
Termination
This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of a covered person’s death or the date the lump sum benefit amount for heart attack or stroke has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent, as defined in the policy.
Hospital Intensive Care Unit Benefits Pays a daily benefit amount, up to the maximum number of days for any combination of confinement, for each day charges are incurred for room and board in an intensive care unit (ICU) or step-down unit due to an accident or sickness. Benefits will be paid beginning on the first day a covered person is confined in an ICU or step-down unit due to an accident or sickness that begins after the effective date of this rider. This benefit will reduce by 50% at age 70.
Limitations and Exclusions
For a newborn child born within the 10-month period following the effective date, no benefits under this rider will be provided for confinements that begin within the first 30 days following the birth of such child. No benefits under this rider will be provided during the first two years following the effective date for confinements caused by any heart condition when any heart condition was diagnosed or treated prior to the end of the 30-day period following the covered person’s effective date. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the effective date.
Optionally Renewable This policy/riders are optionally renewable. The policyholder or we have the right to terminate the policy/riders on any premium due date after the first anniversary following the policy/riders effective date. We must give at least 60 days written notice to the policyholder prior to cancellation.
Portability (Voluntary Plans Only) When you no longer meet the definition of Insured, you will have the option to continue this coverage, including any attached riders. No Evidence of Insurability will be required. Portability must meet all of the following conditions: the certificate has been continuously in force for the last 12 months; we receive a request and payment of the first premium for the portability coverage no later than 30 days after the date you no longer qualify as an eligible insured; and the policy, under which this certificate was issued, continues to be in force on the date you cease to qualify for coverage. All future premiums due will be billed directly to you. You are responsible for payment of all premiums for the portability coverage. The benefits, terms and condition of the portability coverage will be the same as those elected under the certificate immediately prior to the date you exercised portability. Portability coverage may include any eligible dependents who were covered under the certificate at the time you ceased to qualify as an eligible insured. No new eligible dependents may be added to the portability coverage except as provided in the New Born and Adopted Children provision. No increases in coverage will be allowed while you are exercising your rights under this rider. The premium for the portability coverage will be based on the premium tables used for such coverage at the time of the portability request. Coverage under this rider will terminate in accordance with the provisions of the Termination of Coverage in the certificate. If the policy is no longer in force, then portability coverage is not available.
We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in the armed forces, or military service for any country at war [(if coverage is suspended for any covered person during a period of military service, we will refund the pro-rata portion of any premium paid for any such covered person upon receipt of the policyholder’s written request)]; participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; participation in, or attempting to participate in, a felony, riot or insurrection (a felony is defined by the law of the jurisdiction in which the activity takes place).
Termination
This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider or the date of the covered person’s death. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.
2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606
Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For detailed benefits, limitations, exclusions and other provisions, please refer to the policy/certificate/riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC14 Series | TX | Limited Benefit Group Cancer Indemnity Insurance | (10/14) | MGM/FBS | Mansfield ISD 51
APSB-22339(TX)-0615 MGM/FBS Mansfield ISD
VOYA YOUR BENEFITS PACKAGE
Accident
About this Benefit Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-soserious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.
2/3 of disabling injuries suffered by American workers are not work related. American workers 36% ofreport they always or
usually live paycheck
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 52 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Mansfield ISD Benefits Website: www.mybenefitshub.com/mansfieldisd
Accident What is Accident Insurance? Accident Insurance pays you benefits for specific injuries and events resulting from a covered accident that occurs on or after your coverage effective date. The benefit amount depends on the type of injury and care received. You have the option to elect Accident Insurance to meet your needs. Accident Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.
Features of Accident Insurance include: • • •
Guaranteed issue: No medical questions or tests are required for coverage. Flexible: You can use the benefit payments for any purpose you like. Portable: If you leave your current employer or retire, you can take your coverage with you.
How can Accident Insurance help? Below are a few examples of how your Accident Insurance benefits could be used: • Medical expenses, such as deductibles and copays • Home healthcare costs • Lost income due to lost time at work • Everyday expenses like utilities and groceries
Who is eligible for Accident Insurance? You—All active employees working 18+ hours per week. Your spouse*—If you have coverage on yourself, you may enroll your spouse, as long as your spouse is not covered under your employer’s plan as an employee. Your spouse will be covered for the same Accident benefits as you are. Your children**—If you have coverage on yourself; your natural children, stepchildren, adopted children or children for whom you are a legal guardian; are eligible to be covered under your employer’s plan, up to the age of 26. Your children will be covered for the same Accident benefits as you are and one premium amount covers all of your eligible children. If both you and your spouse are covered under this policy as an employee; then only one, but not both, may cover the same children for Accident Insurance. If the parent who is covering the children stops being insured as an employee, then the other parent may apply for children’s coverage.
limitations, go to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any riders. EVENT Accident Hospital Care Surgery Open abdominal, thoracic Surgery exploratory or without repair Blood, plasma, platelets Hospital admission Hospital confinement Per day up to 365 Critical care unit confinement per day, up to 15 days Rehabilitation facility confinement per day for 90 days Coma Duration of 14 or more days Transportation per trip, up to 3 per accident Lodging Per day, up to 30 days Family care per child, up to 45 days Accident care Initial doctor visit Urgent care facility treatment Emergency room treatment Ground ambulance Air ambulance Follow-up doctor treatment Chiropractic treatment up to 6 per accident Medical equipment Physical or occupational therapy up to 6 per accident Prosthetic device (one) Prosthetic device (two or more) Major diagnostic exam Outpatient surgery (1 per accident) X-ray Common injuries Burns second degree, at least 36% of the body Burns 3rd degree, at least 9 but less than 35 square inches of the body Burns 3rd degree, 35 or more square inches of the body Skin grafts Emergency dental work
LOW OPTION
HIGH OPTION
$1,000 $140 $500 $1,125 $350
$2,500 $350 $650 $1,750 $450
$525
$700
$150
$225
$14,500 $650 $150 $20
$20,000 $840 $225 $30
$75 $200 $200 $300 $1,250 $75 $40 $100
$120 $300 $300 $600 $2,500 $120 $75 $250
$40
$75
$625 $1,000 $200 $200 $40
$1,500 $2,400 $500 $300 $75
$1,125
$1,750
$6,000
$10,000
$12,500
$22,000
25% of the 25% of burn burn benefit benefit $300 crown, $480 crown, $75 $180 extraction extraction $80 $120 $275 $420
*The use of “spouse” in this document means a person insured as a spouse as described in the applicable rider. Please contact your employer for more information. **The definition of “child” may vary by state. Please contact your employer for more information.
Eye injury removal of foreign object Eye injury surgery Torn knee cartilage surgery with no repair or if cartilage is
$175
$280
What accident benefits are available?
Torn knee cartilage surgical repair Laceration1 treated no sutures Laceration1 sutures up to 2” Laceration1 sutures 2” – 6” Laceration1 sutures over 6” Ruptured disk surgical repair
$650 $25 $50 $200 $400 $650
$1,000 $60 $120 $480 $960 $1,000
The following list is a summary of the benefits provided by Accident Insurance. You may be required to seek care for your injury within a set amount of time. Note that there may be some variations by state. For a list of standard exclusions and
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Accident EVENT Tendon/ligament/rotator cuff exploratory arthroscopic surgery with no repair
Tendon/ligament/rotator cuff one, surgical repair
Tendon/ligament/rotator cuff two or more, surgical repair
Concussion Paralysis - paraplegia Paralysis - quadriplegia Dislocations Hip joint Knee Ankle or foot bone(s) other than toes Shoulder Elbow Wrist Finger/toe Hand bone(s) other than fingers Lower jaw Collarbone Partial dislocations Fractures Hip Leg Ankle Kneecap Foot excluding toes, heel Upper arm Forearm, hand, wrist except fingers Finger, toe Vertebral body Vertebral processes Pelvis except coccyx Coccyx Bones of face except nose Nose Upper jaw Lower jaw Collarbone Rib or ribs Skull – simple except bones of face Skull – depressed except bones of face Sternum Shoulder blade Chip fractures
LOW OPTION
HIGH OPTION
$350
$720
$675
$1,020
$1,000
$1,520
$175 $13,500 $20,000 Closed/open reduction2 $3,200/$6,400 $2,000/$4,000 $1,200/$2,400 $1,500/$3,000 $900/$1,800 $900/$1,800 $250/$500 $900/$1,800 $900/$1,800 $900/$1,800 25% of the closed reduction amount Closed/open reduction3 $2,500/$5,000 $1,800/$3,600 $1,500/$3,000 $1,500/$3,000 $1,500/$3,000 $1,750/$,3500 $1,500/$3,000 $200/$400 $2,800/$5,600 $1,200/$2,400 $2,750/$5,500 $300/$600 $1,000/$2,000 $500/$1,000 $1,250/$2,500 $1,200/$2,400 $1,200/$2,400 $350/$700 $1,250/$2,500 $2,500/$5,000 $300/$600 $1,500/$3,000 25% of the closed reduction amount
$450 $20,000 $30,000 Closed/open reduction2 $4,000/$8,000 $3,000/$6,000 $1,800/$3,600 $2,200/$4,400 $1,500/$3,000 $1,500/$3,000 $350/$700 $1,500/$3,000 $1,500/$3,000 $1,500/$3,000 25% of the closed reduction amount Closed/open reduction3 $5,000/$10,000 $2,800/$5,600 $2,500/$5,000 $2,500/$5,000 $2,500/$5,000 $2,750/$5,500 $2,500/$5,000 $400/$800 $4,200/$8,400 $2,000/$4,000 $4,000/$8,000 $500/$1,000 $1,400/$2,800 $750/$1,500 $1,750/$3,500 $2,000/$4,000 $2,000/$4,000 $600/$1,200 $1,750/$3,500 $5,000/$10,000 $500/$1,000 $2,500/$5,000 25% of the closed reduction amount
1 Laceration benefits are a total of all lacerations per accident. 2 Closed Reduction of Dislocation = Non-surgical reduction of a completely separated joint. Open Reduction of Dislocation = Surgical reduction of a completely separated joint. 3 Closed Reduction of Fracture = Non-surgical. Open Reduction of Fracture = Surgical. This is a summary of benefits only. A complete description of benefits, limitations, exclusions and termination of coverage will be provided in the certificate of insurance and riders. All coverage is subject to the terms and conditions of the group policy. If there is any discrepancy between this document and the group policy documents, the
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policy documents will govern. To keep coverage in force, premiums are payable up to the date of coverage termination. Accident Insurance is underwritten by ReliaStar Life Insurance Company (Minneapolis, MN), a member of the Voya® family of companies. Policy Form #RL-ACC3-POL-16; Certificate Form #RL- ACC3-CERT-16; and Rider Forms: Spouse Accident Rider Form #RL-ACC3-SPR-16, Children's Accident Rider Form #RLACC3- CHR-16, Wellness Benefit Rider Form #RL-ACC3-WELL-16, Accidental Death & Dismemberment (AD&D) Rider Form #RL-ACC3- ADR-16. Form numbers, provisions and availability may vary by state. EB0917-44956-0919 Mansfield Independent School District, Group #69514-9, Acct #001 Date Prepared: 10/08/2018 177546-09302018
Accident may vary by state.) The benefits listed below are included with your Accident Insur- Benefits are not payable for any loss caused in whole or directly by any of the following*: ance coverage. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete descrip- • Participation or attempt to participate in a felony or illegal activity. tion of your available benefits, exclusions and limitations, see • An accident while the covered person is operating a motorized your certificate of insurance and any riders. vehicle while intoxicated. Intoxication means the covered perWellness Benefit: This provides an annual benefit payment if you son’s blood alcohol content meets or exceeds the legal precomplete a health screening test. sumption of intoxication under the laws of the state where the • The annual benefit amount is $50 for completing a health accident occurred. screening test. • Suicide, attempted suicide or any intentionally self-inflicted • Your spouse’s benefit amount is $50. injury, while sane or insane. • The benefit for child coverage is 50% of your benefit amount • War or any act of war, whether declared or undeclared, other per child, with an annual maximum of $100 for all children. than acts of terrorism. • Loss sustained while on active duty as a member of the armed Accidental Death and Dismemberment (AD&D) coverage: If you forces of any nation. We will refund, upon written notice of are severely injured or die as a result of a covered accident, an such service, any premium which has been accepted for any AD&D benefit may be payable to you or your beneficiary. period not covered as a result of this exclusion. • Common carrier: If the death occurs as a result of a covered • Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, accident on a common carrier, a higher benefit will be payaother than under the direction of a doctor. ble. Common carrier means any commercial transportation • Riding in or driving any motor-driven vehicle in a race, stunt that operates on a regularly scheduled basis between predeshow or speed test. termined points or cities. • Operating, or training to operate, or service as a crew member Accidental Death Benefits Low Option High Option of, or jumping, parachuting or falling from, any aircraft or hot Common Carrier* air balloon, including those which are not motor-driven. Flying Employee $85,000 $200,000 as a fare-paying passenger is not excluded. Spouse $40,000 $100,000 • Engaging in hang-gliding, bungee jumping, parachuting, sail Children $20,000 $50,000 gliding, parasailing, parakiting, kite surfing or any similar activiOther Accident ties. Employee $40,000 $100,000 • Practicing for, or participating in, any semi-professional or proSpouse $15,000 $40,000 fessional competitive athletic contests for which any type of Children $8,000 $20,000 compensation or remuneration is received. *If the death occurs as a result of a covered accident on a common carrier a higher benefit will be paid. Common • Any sickness or declining process caused by a sickness. carrier means any commercial transportation that operates on a regularly scheduled basis between predetermined How much does Accident Insurance cost? points or cities. All employees pay the same rate, no matter their age. See the Accidental Dismemberment chart below for the premium amounts. Benefits Loss of both hand or both feet Monthly Rates (12 Pay Periods) $24,000 $40,000 or sight in both eyes Employee Employee Employee Family Loss of one hand or one foot and Spouse and Children $18,000 $30,000 AND the sight of one eye Low Option $11.53 $19.29 $21.83 $29.59 Loss of one hand AND one foot $18,000 $30,000 High Option $19.05 $31.33 $35.46 $47.74 Loss of one hand OR one foot $10,000 $15,000 Semi-Monthly Rates (18 Pay Periods) Loss of Two or more fingers or $1,500 $2,500 Employee Employee toes Employee Family and Spouse and Children Loss of one finger or one toe $1,000 $1,500 Low Option $7.69 $12.86 $14.55 $19.73 Questions High Option $12.70 $20.89 $23.64 $31.83 For more information, please contact or go to: Semi-Monthly Rates (26 Pay Periods) Voya Employee Benefits Customer Service at (877) 236-7564 Employee Employee Employee Family and Spouse and Children Exclusions and Limitations* Low Option $5.32 $8.90 $10.08 $13.66 Exclusions for the Certificate, Spouse Accident Insurance, and High Option $8.79 $14.46 $16.37 $22.03 Children’s Accident Insurance and AD&D are listed below. (These
What does my Accident Insurance include?
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VOYA
Critical Illness
YOUR BENEFITS PACKAGE
About this Benefit Critical illness insurance is designed to supplement your medical and disability coverage easing the financial impacts by covering some of your additional expenses. It provides a benefit payable directly to the insured upon diagnosis of a covered condition or event, like a heart attack or stroke.
$16,500 Is the aggregate cost of a hospital stay for a heart attack.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 56 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Mansfield ISD Benefits Website: www.mybenefitshub.com/mansfieldisd
Critical Illness What is Critical Illness Insurance?
How can Critical Illness Insurance help?
Critical Illness Insurance pays a lump-sum benefit if you are diagnosed after your effective date of coverage with a covered illness or condition listed below. Please review certificates of coverage for any limitations that may apply. Critical Illness Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.
Below are a few examples of how your Critical Illness Insurance benefit could be used (coverage amounts may vary): • Medical expenses, such as deductibles and copays • Child care • Home healthcare costs • Mortgage payment/rent and home maintenance
Features of Critical Illness Insurance include: • Guaranteed Issue: No medical questions or tests required for coverage. • Flexible: You can use the benefit money for any purpose you like. • Payroll deductions: Premiums are paid through convenient payroll deductions. • Portable: Should you leave your current employer or retire, you can take your coverage with you.
• •
For what critical illnesses and conditions are benefits available? Critical Illness Insurance provides a benefit for the following illnesses and conditions. Covered illnesses/conditions are broken out into groups called “modules”. Benefits are paid at 100% of the Maximum Critical Illness Benefit amount unless otherwise stated. For a complete description of your benefits, along with applicable provisions, conditions on benefit determination, exclusions and limitations, see your certificate of insurance and any riders. Base Module • Heart attack • Stroke • Coronary artery bypass (25%) • Coma • Major organ failure • Permanent paralysis • End stage renal (kidney) failure Module A • Benign brain tumor • Deafness • Occupational HIV • Blindness Module B • Multiple sclerosis • Amyotrophic lateral sclerosis (ALS) • Parkinson’s disease • Alzheimer’s disease • Infectious disease Cancer Module • Cancer • Skin cancer (10%) • Carcinoma in situ (25%)
Who is eligible for Critical Illness Insurance? •
You—all active employees working 18 hours per week. Your spouse*— Coverage is available only if employee coverage is elected. Your child(ren)— to age 26. Coverage is available only if employee coverage is elected.
*The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider.
What Maximum Critical Illness Benefit am I eligible for? • •
•
For you You have the opportunity to purchase a Maximum Critical Illness Benefit of $5,000 - $30,000 in $5,000 increments. For your spouse You also have the opportunity to purchase a Maximum Critical Illness Benefit of $5,000 - $30,000 in $5,000 increments. For your children You also have the opportunity to purchase a Maximum Critical Illness Benefit of $1,000, $2,500, $5,000, $10,000 or $20,000 for each covered child.
How many times can I receive the Maximum Critical Illness Benefit? Usually you are only able to receive the Maximum Critical Illness Benefit for one covered illness or disease within each module. Your plan includes the Restoration Benefit, which provides a onetime restoration of 100% of the maximum benefit amount in order to pay an additional benefit if you experience a second covered illness for a different condition. Your plan also includes the Recurrence Benefit, which allows you to receive a benefit for the same condition a second time. It’s important to note that in order for the second covered illness or the second occurrence of the illness to be covered, it must occur after 12 consecutive months without the occurrence of any covered critical illness named in your certificate, including the illness from the first benefit payment. If a partial benefit is paid out, it will not reduce the available maximum benefit amount for the illnesses or diseases in that same module. If you have reached the benefit limit by receiving the maximum benefit in each module, you may choose to end your coverage; however, if you have coverage for your spouse and/or child(ren), you must continue your coverage in order to keep their coverage active. Please see the certificate of coverage for details. 57
Critical Illness What optional benefits are available? You may choose to include the optional benefits below with your critical illness coverage. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete description of your available benefits, along with applicable provisions, exclusions and limitations, see your certificate of insurance and any riders. Spouse Critical Illness Insurance: If you have coverage for yourself, you may enroll your spouse, as long as your spouse is not covered under the Policy as an employee • Your spouse will receive coverage for the same covered conditions as you. • Your spouse will be able to receive a benefit the same number of times as you, as outlined above. • Guaranteed issue: No medical questions or tests required for coverage. *The use of “spouse” in this form means a person insured as a spouse as described in the certificate of insurance or benefit. Please contact your employer for more information.
Children’s Critical Illness Insurance: As long as you have critical illness coverage on yourself, your natural child(ren), stepchild (ren), adopted child(ren) or child(ren) for whom you are a legal guardian are eligible to be covered under your employer’s plan, up to the age of 26. • Your children are covered for the same covered conditions as you are with the exception of carcinoma in situ and coronary artery bypass; however, actual benefit amounts may vary. • Your child(ren) will be able to receive a benefit the same number of times as you, as outlined above. • One premium amount covers all of your eligible children. • Guaranteed issue: No medical questions or tests required for coverage. • If both you and your spouse are covered under the policy as an employee, then only one, but not both, may cover the same child(ren) under this benefit. If the parent who is covering the child(ren) stops being insured as an employee then the other parent may apply for children’s coverage. Wellness Benefit: This provides an annual benefit payment if you complete a health screening test. You may only receive a benefit once per year, even if you complete multiple health screening tests. • Examples of health screening tests include but are not limited to: Pap test, serum cholesterol test for HDL and LDL levels, mammography, colonoscopy, and stress test
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• •
on bicycle or treadmill. The annual benefit is $75 for completing a health screening test. If your spouse and/or children are covered for Critical Illness Insurance, they are also covered by the Wellness Benefit. Your spouse’s benefit amount is also $75. The benefit for child coverage is 50% of your coverage with an annual maximum of $150 for children’s benefits.
Exclusions and Limitations Benefits are not payable for any critical illness caused in whole or directly by any of the following*: • Participation or attempt to participate in a felony or illegal activity. • Suicide, attempted suicide or any intentionally selfinflicted injury, while sane or insane. • War or any act of war, whether declared or undeclared, other than acts of terrorism. • Loss that occurs while on full-time active duty as a member of the armed forces of any nation. We will refund, upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion. • Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor. Benefits reduce 50% for the employee and/or covered spouse on the policy anniversary following the 70th birthday, however, premiums do not reduce as a result of this benefit change. *See the certificate of insurance and any riders for a complete list of available benefits, along with applicable provisions, exclusions and limitations.
Who do I contact with questions? For more information, please call the Voya Employee Benefits Customer Service Team at (800) 955-7736.
Critical Illness How much does Critical Illness Insurance cost? See the chart below for the premium amounts. Rates shown are guaranteed until September 1, 2020. Employee Coverage—Uni-Tobacco Monthly Rates (12 Pay Periods)
Spouse Coverage—Uni-Tobacco Monthly Rates (12 Pay Periods)
Issue $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 Age
Issue $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 Age
30 30-39 40-49 50-59 60-64 65-69 70+
$2.95
$5.90
$8.85
$11.80
$14.75
$17.70
$3.45 $6.90 $10.35 $13.80 $17.25 $5.95 $11.90 $17.85 $23.80 $29.75 $12.05 $24.10 $36.15 $48.20 $60.25 $19.10 $38.20 $57.30 $76.40 $95.50 $24.85 $49.70 $74.55 $99.40 $124.25 $35.90 $71.80 $107.70 $143.60 $179.50 Employee Coverage—Uni-Tobacco Semi-Monthly Rates (18 Pay Periods)
$20.70 $35.70 $72.30 $114.60 $149.10 $215.40
Issue $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 Age $1.97 $3.93 $5.90 $7.87 $9.83 30 30-39 $2.30 $4.60 $6.90 $9.20 $11.50 40-49 $3.97 $7.93 $11.90 $15.87 $19.83 50-59 $8.03 $16.07 $24.10 $32.13 $40.17 60-64 $12.73 $25.47 $38.20 $50.93 $63.67 65-69 $16.57 $33.13 $49.70 $66.27 $82.83 70+ $23.93 $47.87 $71.80 $95.73 $119.67 Employee Coverage—Uni-Tobacco Semi-Monthly Rates (26 Pay Periods) Issue $5,000 $10,000 $15,000 $20,000 $25,000 Age $1.36 $2.72 30 30-39 $1.59 $3.18 40-49 $2.75 $5.49 50-59 $5.56 $11.12 60-64 $8.82 $17.63 65-69 $11.47 $22.94 70+ $16.57 $33.14
$13.80 $23.80 $48.20 $76.40 $99.40 $143.60
$30,000
$4.08
$5.45
$6.81
$8.17
$4.78 $8.24 $16.68 $26.45 $34.41 $49.71
$6.37 $10.98 $22.25 $35.26 $45.88 $66.28
$7.96 $13.73 $27.81 $44.08 $57.35 $82.85
$9.55 $16.48 $33.37 $52.89 $68.82 $99.42
Coverage Amount $1,000 $2,500 $5,000 $10,000 $20,000
$11.80
30 30-39 40-49 50-59 60-64 65-69 70+
$3.50 $3.95 $6.80 $14.95 $23.60 $26.95 $40.70
$7.00
$10.50
$14.00
$17.50
$21.00
$7.90 $11.85 $15.80 $19.75 $13.60 $20.40 $27.20 $50.50 $29.90 $44.85 $59.80 $74.75 $47.20 $70.80 $94.40 $118.00 $53.90 $80.85 $107.80 $134.75 $81.40 $122.10 $162.80 $203.50 Spouse Coverage—Uni-Tobacco Semi-Monthly Rates (18 Pay Periods)
$23.70 $40.80 $89.70 $141.60 $161.70 $244.20
Issue $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 Age 30 30-39 40-49 50-59 60-64 65-69 70+
$2.33 $2.63 $4.53 $9.97 $15.73 $17.97 $27.13
$4.67
$7.00
$9.33
$11.67
$14.00
$5.27 $7.90 $10.53 $13.17 $9.07 $13.60 $18.13 $33.67 $19.93 $29.90 $39.87 $49.83 $31.47 $47.20 $62.93 $78.67 $35.93 $53.90 $71.87 $89.83 $54.27 $81.40 $108.53 $135.67 Spouse Coverage—Uni-Tobacco Semi-Monthly Rates (26 Pay Periods)
$15.80 $27.20 $59.80 $94.40 $107.80 $162.80
Issue $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 Age 30 30-39 40-49 50-59 60-64 65-69 70+
$1.75
$3.50
$5.25
$6.46
$8.08
$1.98 $3.40 $7.48 $11.80 $13.48 $20.35
$3.95 $6.80 $14.95 $23.60 $26.95 $40.70
$5.93 $10.20 $22.43 $35.40 $40.43 $61.05
$7.29 $12.55 $27.60 $43.57 $49.75 $75.14
$9.12 $10.94 $15.69 $18.83 $34.50 $41.40 $54.46 $65.35 $62.19 $74.63 $93.92 $112.71
Child(ren) Coverage Monthly Rates Semi-Monthly Rates (12 Pay Periods) (18 Pay Periods) $0.39 $0.26 $0.98 $0.65 $1.95 $1.30 $3.90 $2.60 $7.80 $5.20
$9.69
Semi-Monthly Rates (26 Pay Periods) $0.18 $0.45 $0.90 $1.80 $3.60 59
NBS
FSA (Flexible Spending Account)
YOUR BENEFITS PACKAGE
About this Benefit A Cafeteria Plan is designed to take advantage of Section 125 of the Internal Revenue Code. It allows you to pay certain qualified expenses on a pre-tax basis, thereby reducing your taxable income. You can set aside a pre-established amount of money per plan year in a Healthcare Flexible Spending Account (FSA). Funds allocated to a healthcare FSA must be used during the plan year or are forfeited unless your plan contains a $500 rollover or grace period provision.
Unlimited FSA (Non HSA Compatible) The funds in the unlimited healthcare FSA can be used to pay for eligible medical expenses like deductibles, co-payments, orthodontics, glasses and contacts.
FLIP TO‌ FOR HSA VS. FSA COMPARISON
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This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 60 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Mansfield ISD Benefits Website: www.mybenefitshub.com/mansfieldisd
FSA (Flexible Spending Account) NBS Flexcard You may use the card to pay merchants or service providers that accept MasterCard® credit cards, so there is no need to pay cash up front, then wait for reimbursement. If you are participating in the Dependent Care portion, the money isn’t loaded to the card. You must file web or paper claims or enroll in continual reimbursement.
NBS Prepaid MasterCard® Debit Card
New Plan Participants
When Will I Receive My Flex Card? Expect Flex Cards to be delivered to the address listed in THEbenefitsHUB near the end of September. Don’t forget, Flex Cards Are Good For 3 Years!
NBS Contact Information: 8523 South Redwood Road West Jordan, UT 84088 Phone (800) 274‐0503 Fax (800) 478‐1528 Email: claims@nbsbenefits.com
NBS will mail out your new benefit cards to the address listed in THEbenefitsHUB. They will be sent in unmarked envelopes so please watch for them as they should arrive within 21 business days of effective date. NBS debit cards are good for 3 years.
FSA Annual Contribution Max:
DID YOU KNOW?
$2,700
Dependent Care Annual Max:
FSAs use tax-free funds to help pay for your Health Care Expenses.
$5,000
Account Information: Participant Account Web Access: www.participant.nbsbenefits.com Participants may call NBS and talk to a representative during regular business hours, Monday-Friday, 8 am to 7 pm Central Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to the NBS website: www.NBSbenefits.com • • • • •
Detailed claim history and processing status Health Care and Dependent Care account balances Claim forms, Direct Deposit form, worksheets, etc. Online claim FAQs
For a list of sample expenses, please refer to the Mansfield ISD benefit website: www.mybenfitshub.com/mansfieldisd 61
FSA Frequently Asked Questions What is a Flexible Spending Account? A Flexible Spending Account allows you to save money by paying out-of-pocket health and/or dependent care related expenses with pre-tax dollars. Your contributions are deducted from your pay before taxes are withheld and your account is up fronted with an annual amount. Because you are taxed on a lower amount of pay, you pay less in taxes and you have more to spend.
How does a Flexible Spending Account Benefit Me? A Cafeteria plan enables you to save money on group insurance, health-related expenses, and dependent-care expenses. You may save as much as 35 percent on the cost of each benefit option! Eligible expenses must be incurred within the plan year and contributions are use-it-or- lose-it. Remember to retain all your receipts.
Health Care Expense Account Example Expenses: • • • • • • • • • •
Acupuncture Body scans Breast pumps Chiropractor Co-payments Deductible Diabetes Maintenance Eye Exam & Glasses Fertility treatment First aid
• • • • • • • • •
Hearing aids & batteries Lab fees Laser Surgery Orthodontia Expenses Physical exams Pregnancy tests Prescription drugs Vaccinations Vaporizers or humidifiers
Dependent Care Expense Account Example Expenses: • • • •
Before and After School and/or Extended Day Programs The actual care of the dependent in your home. Preschool tuition. The base costs for day camps or similar programs used as care for a qualifying individual.
What Can I Use My Flexible Spending Account On? For a full list of eligible expenses, please refer to www.mybenfitshub.com/mansfieldisd
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What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)? Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or- lose-it. Remember to retain all your receipts (including receipts for card swipes). Please contact your benefits admin to determine if your district has the grace period or the $500 Roll-Over option. If your district does not have the roll-over, your plan contributions are use-it-or-lose-it.
How Do I File A Claim? In most situations, you will be able to swipe your card however, in the event you lose your card or are waiting to receive one, you can visit www.thebenfitshub.com/ mansfieldisd and complete the “Claim Form” to send to NBS or use the web or phone app to file online.
How To Receive Your Dependent Care Reimbursement Faster. A Direct Deposit form is available on the Benefits Website which will help you get reimbursed quicker!
How the FSA Plan Works You designate an annual election of pre-tax dollars to be deposited into your health and dependent-care spending accounts. Your total election is divided by the number of pay periods in the Plan year and deducted equally from each paycheck before taxes are calculated. By the end of the Plan year, your total election will be fully deposited. However, you may make a claim for eligible health FSA expenses as soon as they are incurred during the Plan year. Eligible claims will be paid up to your total annual election even if you have not yet contributed that amount to your account.
Get Your Money 1. 2. 3. 4.
Complete and sign a claim form (available on our website) or an online claim. Attach documentation; such as an itemized bill or an Explanation of Benefits (EOB) statement from a health insurance provider. Fax or mail signed form and documentation to NBS. Receive your non-taxable reimbursement after your claim is processed either by check or direct deposit.
NBS Flexcard—FSA Pre-paid Benefit Card Your employer may sponsor the use of the NBS Flexcard, making access to your flex dollars easier than ever. You may use the card to pay merchants or service providers that accept credit cards, so there is no need to pay cash up front then wait for reimbursement.
Account Information Participants may call NBS and talk to a representative during our regular business hours, Monday–Friday, 7am to 6pm Mountain Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to our website: www.NBSbenefits.com Information includes: • Detailed claim history and processing status • Health Care and Dependent Care account balances • Claim forms, worksheets, etc. • Online Claim Submission
Enrollment Considerations After the enrollment period ends, you may increase, decrease, or stop your contribution only when you experience a qualifying “change of status” (marriage status, employment change, dependent change). Be conservative in the total amount you elect to avoid forfeiting money that may be left in your account at the end of the year. Your employer may allow a short grace period or rollover after the Plan year ends for you to submit qualified claims for any unused funds.
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WWW.MYBENEFITSHUB.COM/MANSFIELDISD 64